








Glass _ 
Book- 


COPYRIGHT DEPOSIT 


















































BY 


EDWARD NETTLESHIP, F.R.C.S., 

OPHTHALMIC SURGEON AT ST. THOMAS’ HOSPITAL, LONDON ; SURGEON TO THE 
ROYAL LONDON (MOORFIELDS) OPHTHALMIC HOSPITAL. 


REVISED AND EDITED BY 


WM. CAMPBELL POSEY, A. B., M. D., 

« 

OPHTHALMIC SURGEON TO THE HOWARD AND EPILEPTIC HOSPITALS, PHILA¬ 
DELPHIA; ASSISTANT-SURGEON, WILLS’ EYE HOSPITAL; FELLOW OF THE 
COLLEGE OF PHYSICIANS OF PHILADELPHIA; ASSOCIATE MEMBER 
OF THE AMERICAN OPHTHALMOLOGICAL SOCIETY, ETC. 


SIXTH AMERICAN FROM THE SIXTH ENGLISH EDITION. 

WITH A SUPPLEMENT ON EXAMINATIONS FOR 
COLOR-BLINDNESS AND ACUITY OF 
VISION AND HEARING BY 

WILLIAM THOMSON, M. D., 

i 

EMERITUS PROFESSOR OF OPHTHALMOLOGY IN THE JEFFERSON MEDICAL 

COLLEGE OF PHILADELPHIA. 


WITH 5 COLORED PLATES AND 192 ENGRAVINGS. 



LEA BROTHELS & CO., 

PHILADELPHIA AND NEW YORK. 

1900 . 

\ V, 

> ; ’ 

> ^ ? I 

9 I ? 





11372 


64897 


Library of CoiMr-s S 

Two Cortes Rcccnco 

JUN 27 1900 

C»pyrig*t m ity 

9muu L7 y /pot) 

*• Q+ 

StCOMO COPY. 

0 *' vf>*< »# 

0 K0£K DIVISION, 

JUL 7 1900 


dl'I'Y 

. w 


Entered according to the Act of Congress in the year 1900, by 
LEA BROTHERS & CO., 

In the Office of the Librarian of Congress All rights reserved. 


<J\ S'') 











TO 


JONATHAN HUTCHINSON, F.R.S., 

i 

CONSULTING SURGEON TO THE MOORFIELDS OPHTHALMIC 

I 

HOSPITAL AND TO THE LONDON HOSPITAL, ETC.. 


V 


THIS 

BOOK IS DEDICATED 


IN GRATEFUL ADMIRATION OF HIS EMINENT QUALITIES AS A 
CLINICAL TEACHER AND INVESTIGATOR. 


(iii ) 




PREFACE TO THE SIXTH EDITION. 


A work which has passed through the press six times 
in England and six in America has proved its usefulness. 
In certain points the views and practice of American oph¬ 
thalmologists differ from those prevailing in Great Britain, 
hence the publishers have taken the opportunity presented 
by the exhaustion of another edition to have it revised and 
adapted even more completely to the needs of American 
students and practitioners of this branch. They accord¬ 
ingly desired the present Editor to undertake this task, 
and to add whatever was necessary to make it a thoroughly 
up-to-date American text-book. 

The book has been completely revised, therefore, partic¬ 
ular attention being given to the methods of examination 
usually followed in this country, and a number of thera¬ 
peutic measures have been added which have recently been 
largely employed by American ophthalmologists. While 
the text bearing upon the different diseases of the eye has 
been altered as little as possible, as it has been this feature 
of the book particularly which has led to its world-wide 
popularity, the Editor has introduced into the section on 
diseases of the conjunctiva the latest views regarding the 
bacteriological origin of several varieties of conjunctivitis, 
and has given descriptions of several new forms of ocular 
diseases. 

( v ) 




VI 


PREFACE. 


A large number of illustrations have been inserted to 
elucidate the text and to explain the new apparatus which 
has been described, and the section on the visual tests for 
railway employes has been thoroughly revised by Dr. 
Thomson. 

In the Appendix will be found the laws governing the 
visual tests for admission into the public services of the 
United States. These have been obtained from the author¬ 
ities at Washington, and are presented for the first time in 
a collected form, in the hope that they may prove useful 
to those who conduct the examinations of candidates for 
the Army, Navy, and Merchant Marine. The methods 
employed in examining the eyes of school children in 
certain American cities have also been added. 

In conclusion, the Editor desires to express his apprecia¬ 
tion and thanks to Mr. Nettleship and to Mr. W. T. 
Holmes Spicer, the reviser of several English editions of 
the book, for their courtesy and kindness in granting their 
consent to this American edition. 


W. C. P. 


CONTENTS. 


PART I.—MEANS OF DIAGNOSIS. 

PAGE 

List of Abbreviations .17 

CHAPTER I. 

OPTICAL OUTLINES. 

Lenses and prisms; Refraction of the eye, and conditions of 
clear vision; Numeration of spectacle lenses; Table show¬ 
ing the equivalent numbers of lenses made by the inch 
scale and metrical scale respectively . . . 17—30 

CHAPTER II. 

EXTERNAL EXAMINATION OF THE EYE. 

Examination of: 1. The lids; 2. The conjunctival cul-de-sac; 

3. The eyeball; 4. Information derived from the blood¬ 
vessels visible on the surface of the eyeball; 5. The cor¬ 
nea; 6. The iris; 7. The pupils; 8. The lens; 9. The 
mobility of the eyeball; 10. To estimate the tension of 
the eyeball; 11. Testing the acuteness of sight; 12. Ac¬ 
commodation; 13. Balance of external eye-muscles; 14. 

The ophthalmometer ; 15. The field of vision ; 16. Color 
perception.37—57 


CHAPTER III. 

EXAMINATION OF THE EYE BY ARTIFICIAL LIGHT. 

1. Focal or “ oblique” illumination. 

2. Ophthalmoscopic examination : Use of the ophthalmoscope. 

( vii) 



CONTENTS. 


viii 

PAGE 

Indirect method : Appearance of optic disk ; scleral ring, phy¬ 
siological pit, lamina cribrosa; of choroid; of retina; 
vessels, yellow spot, fovea centralis. 

Direct method: Examination of vitreous; Determination of 
refraction ; Table of relation between refraction and length 
of eye ; Examination of fine details by direct method. 

Retinoscopy.. 58—83 


PART II.—CLINICAL DIVISION. 

CHAPTER IV. 

DISEASES OF THE EYELIDS. 

Blepharitis; Stye; Meibomian cyst; Horns and warty forma¬ 
tions ; Molluscum contagiosum ; Xanthelasma ; Pediculus 
pubis. Ulcers: Rodent cancer; Tertiary syphilis; Tuber¬ 
cle of conjunctiva; Lupus; Chancre. Congenital ptosis ; 
Epicantlius; Congenital trichiasis .... 85—93 

CHAPTER V. 

DISEASES OF THE LACHRYMAL APPARATUS 

Epiphora, stillicidium lachrymarum, and lachrymation. 

Epiphora from alterations of punctual and canaliculus; Dacry- 
olitlis. 

Diseases of lachrymal sac and nasal duct: Mucocele and lachry¬ 
mal abscess; Stricture of nasal duct; Lachrymal abscess 
in newborn infants ....... 94—101 


CHAPTER VI. 

DISEASES OF THE CONJUNCTIVA. 

Purulent and gonorrhoeal ophthalmia; Muco-purulent oph¬ 
thalmia; Catarrhal and other forms of muco-purulent 
ophthalmia; Follicular conjunctivitis; Membranous and 
diphtheritic ophthalmia; Granular ophthalmia; Results 
of granular ophthalmia; Pannus, distichiasis and trichia- 



I 


CONTENTS. 


sis ; Organic entropion ; Chronic conjunctivitis; Amyloid 
disease; Spring catarrh ; Conjunctivitis from drugs; Oph¬ 
thalmia nodosa; Primary shrinking of conjunctiva; 
Snow-blindness.101—124 


CHAPTER VII. 

DISEASES OF THE CORNEA. 

A. Ulcers and non-specific inflammation. 

Appearances of the cornea in disease: “Steamy” and 
“ground-glass” cornea; Infiltration; Swelling; Ulcera¬ 
tion ; Nebula and leucoma. 

Symptoms in ulceration; Photophobia ; Congestion ; 

Pain. 

Clinical types of ulcer: Simple ulcer; Facetting ulcer; 
Phlyctenular affections; Phlyctenular, or recurrent vas¬ 
cular ulcer; Marginal conjunctivitis. (Spring catarrh); 
Crescentic ulcer of old age; Infective ulcers; Abscess and 
suppurating ulcer; Hypopyon; Onyx; Keratomalacia; 
Herpes; Superficial punctate keratitis. 

Treatment of ulcers of cornea. 

B. Diffuse keratitis. 

Syphilitic keratitis. Other affections of the cornea: 
Keratitis punctata; Corneal changes in glaucoma; Conical 
cornea; Buphtlialmos (Hydrophthalmos); Calcareous 
film; Arcus senilis; Inflammatory arcus; Opacity from 
use of lead lotion; Staining of conjunctiva or cornea 
from use of nitrate of silver ..... 125—152 

CHAPTER VIII. 

DISEASES OF THE IRIS. 

Iritis, symptoms: Muddiness and discoloration of iris; Syn- 
echiae; Corneal haze; Ciliary congestion; Pain; Lymph 
nodules; Hypopyon. 

Results of iritis. 

Causes: Syphilis; Rheumatism; Gout; Sympathetic 
disease; Injuries and local causes; Chronic iritis. 

Treatment of iritis. 

Congenital irideremia; Coloboma; Persistent pupillary mem¬ 
brane. ......... 153—165 


X 


CONTENTS. 


CHAPTER IX. 

DISEASES OF THE CILIARY REGION. 

PAGE 

Episcleritis (or scleritis), sclero-keratitis and allied diseases: 
Cyclitis (iridochoroiditis, “serous iritis”); Traumatic 
cyclitis (or panophthalmitis). 

Sympathetic affections; Sympathetic irritation; Sympathetic 

inflammation; Treatment ..... 166—179 

CHAPTER X. 

INJURIES OF THE EYEBALL. 

Contusion and concussion injuries: Rupture of eyeball; Intra¬ 
ocular hemorrhage; Detachment of iris; Dislocation of 
lens; Detachment of retina; Rupture of choroid; Paral¬ 
ysis of iris and ciliary muscle; Iritis; Commotio retinae; 
Traumatic myopia. Treatment of blows on eye; Dislo¬ 
cation of lens. 

Surface wounds of eyeball: Abrasion and foreign body on 
cornea; Foreign body on conjunctiva. 

Burns and scalds; Prognosis uncertain for some days: Lime- 
burn ; Serious results of severe burns. 

Penetrating wounds of eyeball; Slight cases; Severe cases; 
Traumatic cataract; Cyclitis; Foreign body in eye. Treat¬ 
ment. Rules as to the excision of wounded eyes. Electro¬ 
magnet for removing bits of iron.180—190 

CHAPTER XI. 

CATARACT. 

Senile changes in lens. 

Definition of cataract: General cataract: Nuclear and 
cortical, each may be hard (senile) or soft (juvenile); 
Congenital. Partial cataract; Lamellar; Pyramidal; 
Anterior and posterior polar. Cataract following wound 
or concussion of eyeball. 

Primary and secondary cataract. 

Symptoms and diagnosis of cataract. Prognosis before and 
after operation. 


CONTENTS. 


xi 


. . PAGE 

Treatment: Palliative; Atropine. Radical; Extraction; Dis¬ 
cission or solution; Suction. 

Rules as to operating for cataract; Artificial ripening 
of cataract; Causes of failure after extraction ; Hemor¬ 
rhage; Suppuration of globe; Iritis; Prolapse of Iris; 
Influence of lachrymal disease. 

Sight after removal of cataract. 

Treatment of lamellar cataract. 

Cataract following injury; Dislocation of lens . 191—212 

CHAPTER XII. 

DISEASES OF THE CHOROID. 

Participation by the retina and the vitreous. 

Appearance in health ; Appearance in disease: Atrophy, pig¬ 
ment in choroid and retina ; Exudations, syphilitic, tuber¬ 
cular; Rupture; “ Colloid ” change ; Hemorrhages. 

Clinical forms of disease: Syphilitic choroiditis disseminata; 
Myopic changes; Central senile choroiditis; Pseudo¬ 
glioma ; Other forms. 

Coloboma; Albinism.213—228 

CHAPTER XIII. 

DISEASES OF THE RETINA. 

Appearances in health : Bloodvessels, yellow spot, and “halo” 
around it; “ Opaque nerve-fibres.” 

Appearances in disease: Congestion ; Retinitis, diffuse, 
localized, with white spots and hemorrhages, solitary patch. 

Hemorrhage; Pigmentation ; Atrophy; Disk in atrophy of 
retina; Detachment. 

Clinical forms of disease: Syphilitic retinitis; Albuminuric; 
Hemorrhagic; Retinitis apoplectica and large single 
hemorrhages; Embolism and thrombosis; Retinitis pig¬ 
mentosa ; Retinitis from intense light . . . 229—253 

CHAPTER XIV. 

DISEASES OF THE OPTIC NERVE. 

Relation between changes at the disk, disease of the optic 
nerve, and affection of sight. 

Pathological changes in optic nerve. 


CONTENTS. 


• • 

Xll 

PAGE 

Appearances of optic disk in disease: Inflammation, optic 
neuritis, papillitis, or choked disk; Atrophy after papil¬ 
litis; Papillo-retinitis. 

Etiology of papillitis. Retro-ocular neuritis; Syphilis 
causing papillitis. 

Atrophy of disk: Appearances and causes; Clinical 
aspects; State of sight, field of vision, and color per¬ 
ception ; A. Double atrophy; B. Single atrophy . 254—268 

CHAPTER XY. 

AMBLYOPIA AND FUNCTIONAL DISORDERS OF SIGHT. 

“Amblyopia” and “amaurosis:” Single amblyopia: From 
suppression or congenital defect; From defective images ; 

From retro-ocular neuritis. Double amblyopia: Central 
amblyopia (tobacco amblyopia). 

Hemianopia; Hysterical amblyopia and hypercesthesia oculi; 
Asthenopia 

Functional disorders of vision; Endemic nyctalopia; Heme¬ 
ralopia; Colored vision; Micropsia; Muscse volitantes; 
Diplopia; Malingering; Color-blindness . . . 269—285 

CHAPTER XVI. 

DISEASES OF THE VITREOUS HUMOR. 

Usually secondary to other disease of eye. 

Examination for opacities: Cholesterine; Blood ; Blood¬ 
vessels in vitreous; Cysticercus. 

Conditions causing disease of vitreous: Myopia; Blows and 
wounds; Spontaneous hemorrhoge; Cvclitis, choroiditis, 
retinitis; Sympathetic disease ..... 286—290 

CHAPTER XVII. 

GLAUCOMA. 

Primary and secondary. 

Primary glaucoma: Premonitory stage ; Chronic or Simple ; 
Subacute; Acute ; Absolute. 


CONTENTS. 


x 111 


PAGE. 

Ophthalmoscopic changes ; Clipping of disk. 

Symptoms explained; Mechanism. 

General and diathetic causes; Treatment; Prognosis 
Secondary glaucoma; Conditions causing it . . . 291—310 

CHAPTER XVIII. 

TUMORS AND NEW-GROWTHS. 

A. Of the conjunctiva and front of the eyeball. Cauliflower 

wart; Lupus; Syphilitictarsitis; Pinguecula; Pterygium; 
Lymphatic cysts; Dermoid tumor ; Episcleritis simulat¬ 
ing tumor; Fibro fatty growth; Cystic tumors; Fibrous 
and Bony tumors ; Epithelioma; Sarcoma. 

B. Intraocular tumors. Glioma of retina; Sarcoma of 

choroid ; Tubercular tumor of choroid. Tumors of iris : 
Sarcoma; Sebaceous tumor; Cysts; Granuloma . 311—320 

CHAPTER XIX. 

INJURIES, DISEASES, AND TUMORS OF THE ORBIT. 

Contusion and concussion injuries. Emphysema of orbit; 
Traumatic ptosis. 

Abscess and cellulitis of orbit; Inflammation and abscess of 
lachrymal gland. 

Wounds: Of eyelids; of orbit; Large foreign bodies in orbit. 
Tumors of orbit. General symptoms: Distention of frontal 
sinus; Ivory exostosis; Tumors growing from parts around 
the orbit; Pulsating exophthalmos; Cystic tumors; Solid 
intraorbital tumors. Naevus. Dermoid tumor in eye¬ 
brow ......... 321—328 


CHAPTER XX. 

ERRORS OF REFRACTION AND ACCOMMODATION. 

Emmetropia ; Ametropia. 

Myopia. Symptoms: Insufficiency of internal recti. Poste¬ 
rior staphyloma and crescent; Other complications; Tests 
for causes; Measurement of degree; Treatment; Spec¬ 
tacles ; Tenotomy. 

Hypermetropia. Symptoms: Accommodative asthenopia; 
Tests for hypermetropia; Treatment; Spectacles. 



XIV 


CONTENTS . 


PAGE. 

Astigmatism. Regular and irregular; Seat; Focal interval; 
Cylindrical lenses ; Forms of regular astigmatism ; Detec¬ 
tion and measurement; Spectacles. 

Unequal refraction in the two eyes (anisometropia). 

Presbyopia: Rate of progress ; Treatment: Range and region 

of accommodation in E., M., and H 329—364 

CHAPTER XXI. 

STRABISMUS AND PARALYSIS. 

Definition of strabismus; Diplopia ; True and false image ; 
Homonymous and crossed diplopia ; Suppression of false 
image. 

Causes: Strabismus from over-action ; from weakness; from 
disuse; from weakness following tenotomy; from paral¬ 
ysis. 

Paralysis of sixth nerve (external rectus); of fourth nerve 
(superior oblique); of third nerve; Ophthalmoplegia 
externa; Primary and secondary strabismus; Giddiness 
in paralytic strabismus. 

Affections of internal muscle of eye: Physiology and action 
of drugs on the internal muscles; Affections of pupil 
alone; of accommodation alone ; of pupil and accommo¬ 
dation ; Ophthalmoplegia interna. 

Causes of external ocular paralyses: Syphilitic 
growths; Meningitis ; Tumors ; Rheumatism ; Causes of 
internal ocular paralyses; Treatment. 

Nystagmus. ......... 365—392 


CHAPTER XXII. 

OPERATIONS. 

A. On the eyelids. 

Epilation ; Eversion of lid ; Meibomian cyst; Inspection 
of cornea; Spasmodic entropion; Organic entropion and 
trichiasis ; Ectropion ; Blepliaroplasty ; Ptosis; Cantho- 
plasty ; Peritomy ; Symblepharon. 

B. On the lachrymal apparatus. 

Lachrymal abscess; Slitting canaliculus; Stricture of 
nasal duct, (1) probing, ^2) incising, ( 3) syringing. 



CONTENTS. 


xv 


PACE. 

C For strabismus. 

Tenotomy: Graefe’s; Critchett’s; Liebreich’s; Readjust¬ 
ment and advancement. 

D. Excision of the eye and alternative operations: Abscission, 

optico-ciliary neurotomy, evisceration. 

E. On the cornea. 

Foreign body ; Paracentesis ; Corneal section for ulcer ; 
Conical cornea. 

F. On the iris. 

Iridectomy : For artificial pupil ; for glaucoma. Irido- 
desis; Iridotomy (iritomy). 

Sclerotomy. 

G. For cataract. 

Extraction: Linear ; Graefe’s “modified linear Short 
flap ; Corneal section; Old flap; Complication during 
extraction ; Treatment after extraction ; Secondary opera¬ 
tions ; Discission or solution ; Suction; Treatment after 
solution and suction. 

Anaesthesia in ophthalmic surgery . . . 393—445 


PART III.—DISEASES OF THE EYE IN RELA¬ 
TION TO GENERAL DISEASES. 

CHAPTER XXIII. 

A. GENERAL DISEASES. 

Eye diseases caused by: Syphilis, acquired and inherited, dis¬ 
eases of optic nerve and oculomotor nerves in relation to 
syphilis; Smallpox, scarlet fever, typhus, etc.; diphtheria; 
Measles ; Mumps ; Chicken-pox and whooping-cough ; 
Malarial fevers ; Relapsing fever; Epidemic cerebro¬ 
spinal meningitis; Purpura and scurvy; Pyaemia and 
Septicaemia ; Lead-poisoning ; Alcohol; Tobacco ; Bisul¬ 
phide of carbon ; Quinine ; Kidney disease ; Diabetes; 
Leucocythaemia; Pernicious anaemia; Heart disease ; 
Tuberculosis ; Rheumatism and gonorrhoeal rheumatism; 

Gout, personal and inherited ; Struma; Entozoa. 




XVI 


CONTENTS. 


B. LOCAL DISEASE AT A DISTANCE FROM THE EYE. 

PAGE 

Eye symptoms caused by: Megrim ; Neuralgia and sympathetic 
disease; Diseases of brain; Cerebral tumor; Syphilitic 
disease; Meningitis; Cerebritis; Hydrocephalus; Diseases 
of spinal cord; Myelitis; Locomotor ataxy; General par¬ 
alysis of insane; Lateral and insular sclerosis; Motor 
disorders of eyes and affections of the pupils in cerebral 
and spinal disease. 

C. THE EYE SHARING IN A LOCAL DISEASE OF THE 

NEIGHBORING PARTS. 

Eye symptoms caused by: Herpes zoster of fifth nerve; Para¬ 
lysis of fifth, of facial, and of cervical sympathetic nerves; 
Exophthalmic goitre; erysipelas and orbital cellulitis. 

The teeth in inherited syphilis . 447-478 


[SUPPLEMENT. 

Instructions for examination of railway employes as to vision, 
color-blindness, and hearing; Acuteness of vision; Range 
of vision ; Field of vision ; Color-sense ; Hearing ; Ex¬ 
planations . 479-511] 


APPENDIX. 


Formulae.513 

Bandages. Shades. Protective glass.526 

Test types, etc..529 

Ophthalmoscopes.530 

Perimeters. 533 

Requirements of candidates for public services . . . 536 


Method of examining the eyes of scholars in the public schools 539 


Index 


541 









PART I. 

MEANS OF DIAGNOSIS. 


The following abbreviations will be used in this work: 


Acc. 

Accommodation. 

P- 


Punctum proximum, • 

As. 

Astigmatism. 



or near point. 

Ax. 

Axis of cylindrical 

Pr. 


Presbyopia. 


lenses. 

r. 


Punctum remotissi- 

B. 

Base of prism. 



sum,or far point. 

C. or Cv 

mi 

. Cylindrical lens. 

S. or 

Sph. 

Spherical lenses. 

D. 

Dioptre. 

T. 


Tension; Tn, normal 

E. 

Emmetropia. 



tension; + T, 

IT. 

Hypermetropia. 



increased, and 

m. 

Metre; cm. centime- 



— T, dimin- 


tre; mm. milli- 



islied tension. 


metre. 

Y. 


Visual acuity. 

M. 

Myopia. 

y. s. 


Yellow spot of the 

0. D. 

Optic disc. 



retina. 


CHAPTER 

I. 



OPTICAL OUTLINES. 

1. Kays of light are deviated or refracted when they 
pass from one transparent medium, e. g., air, into another 
of different density, e. g. y water or glass. 

2. If the time occupied by light in passing through a given 
distance in air be taken as the time occupied in passing the 

2 (17) 






18 


MEANS OF DIAGNOSIS. 


same distance in crown glass of which ordinary lenses are 
made is 1.5, and for rock crystal, “ pebble” of opticians, 
1.66, such a number is the “refractive index” of the 
substance. Every ray is refracted except the one which 
falls perpendicularly to the surface, Fig. 1, a. 

3. In passing from a less into a more refractive medium 
the deviation is always toward the perpendicular to the 
refracting surface; in passing from a more into a less 
refracting medium it is always, and to the same extent, 
away from the perpendicular, Fig. 1, b — i. e., the angle x 
in the figure = the angle y. 


Fig. 1. 



Refraction by a medium with parallel sides. 


4. Hence, if the sides of the medium, Fig. 1, m, be par¬ 
allel, the rays on emerging (&') are restored to their original 
direction (6), and, if the medium be thin, very nearly to 
their original path. 

5. But if, as in a prism, the sides of m form an angle, 
Fig. 2, a, the angles of incidence and emergence, x and y, 
still being equal, b' must also form an angle with b. The 
angle a is the “ refracting angle” or edge of the prism; 
the opposite side is the “ base.” The figure shows that 
light is always deviated toward the base. The deviation, 
shown by the angle d, is equal to about half the refracting 
angle a if the prism be of crown glass. The relative direc- 



OPTICAL OUTLINES. 


19 


tion of the rays is not changed by a prism; if parallel or 
divergent before incidence, they are parallel or similarly 
divergent after emergence, Fig. 3. 


Fig. 2. 



Refraction by a prism. 


6. An object seems to lie, or is “ projected,” in the direc¬ 
tion which the rays have as they enter the eye; oh , Fig. 
3, seen by an eye at a' or b', seems to be at o'b, where it 
would be if the rays a' b' had undergone no deviation. 


Fig. 3. 



Apparent displacement of object by a prism. 


7. For very thin prisms the deviation a and /?, Fig. 4, 
remains the same for varying angles of incidence. For 
thin lenses this is expressed by saying that the angle d, Fig. 
5, is the same for the rays at a a ', b b\ and c c', incident at 
different angles, but at the same distance from the axis. 




20 


MEANS OF DIAGNOSIS. 


8. An ordinary lens is a segment of a sphere, plano¬ 
convex or plano-concave, or of two spheres whose centres 
are joined by the axis of the lens (biconvex or biconcave). 


Fig. 4. 



Refraction the same for different angles of incidence. 

9. A lens is regarded as formed of an infinite number of 
minute prisms, each with a different refracting angle. Fig. 
6 shows two such elements of a convex lens, the angle (a) 
of the prism at the edge of the lens being larger, and, 


Fig.5. 



Refraction by a thin lens the same for all rays incident at the same 

distance from the axis. 


therefore, in accordance with § 5, refracting more than y5, 
the angle of the prism near the axis. If two parallel rays, 
a and b, traverse this system a will be more refracted than 
b, and the rays will meet at/. Fig. 7 shows the correspond- 





OPTICAL OUTLINES. 


21 


mg facts for a concave lens by which parallel rays are 
made divergent. 

10. The only ray not refracted by a lens is the one pass¬ 
ing through the centre of each surface, compare § 2, which 

Fig. G. 



Prismatic elements of a convex lens. 

is the principal axis, ax , Fig. 8. Secondary axes are rays 
(such as s. ax) entering and emerging at points on the lens 
parallel to each other, and hence, see § 4, not altered in 
direction ; all rays which pass through the central point of 
the lens are secondary axes, except the principal axis. 

Fig. 7. Fig. 8. 




Prismatic elements of a concave lens. Axes of a lens. 

11. The principal focus, /, Fig. 10, of a lens is the point 
where the rays, a a , that were parallel before they trav¬ 
ersed the lens meet, after they have passed through it; the 
deviation of each ray varying directly with its distance from 
the principal axis, Fig. 6. 

But this is only approximately true. In an ordinary lens 
the rays, a, Fig. 9, which traverse the margin are reflected 






22 


ME A NS OF DIAGNOSIS. 


more, and meet sooner, than the rays ( b ) which lie nearer the 
axis; and the result is, not one focus, but a number of foci. 
“Spherical aberration ” increases with the size of the lens. 
In the eye it is, to a great extent, prevented by the iris, which 
cuts off the light from the margin of the crystalline lens. 

Fig. 9. 



Spherical aberration. 


If parallel rays are incident from the side toward/, Fig. 
10, they will be focussed at /', at the same distance from 
the lens as/; hence every lens has two principal foci— 
anterior and posterior. 

Fig. 10. 



Foci of a convex lens. 


12. Tli epatli of a ray passing from one point to another 
is the same, whatever its direction; the path of the ray b b', 
Fig. 10, is the same, whether it passes from c'/', or in the 
contrary direction. 

13. From § 7 it follows that in Fig. 10 the angles a and 




OPTICAL OUTLINES. 


23 


a' are equal, and hence the ray b, diverging from cf, will 
not meet the axis at/, but at c'/'; cf and cf f' are conju¬ 
gate points , and each is the conjugate focus of the other. 
The angle a or a' remaining the same, then if cf be further 
from the lens c /' will approach it. A ray (c) directed 
toward the axis will be focussed at c"/", because the angle 
a" — a; no real conjugate to c"f" exists; but if the ray 
start fron c" f" it will, on taking the direction c , appear 
to have come from vf which consequently is the virtual 
focus of c" f", see § 6. 

14. All the foci of concave lenses are virtual. In Fig. 
11, a, parallel to the axis, is made divergent (see Fig. 7), 
its virtual focus being at/; similarly cf is the virtual con¬ 
jugate focus of the point emitting the ray b. 


Fig. 11 



Foci of a concave lens. 


15. In equally biconvex or biconcave lenses of crown 
glass the principal focus f is at the centre of curvature of 
either surface of the lens— i. e., f =r, the radius ; in plano¬ 
convex, or concave, lenses/— 2r. 

10. Images. The image formed by a lens consists of foci, 
each of which corresponds to a point on the object. Given 
the foci of the boundary points of an object, we have the 
position and size of its image. 

In Fig. 12 the object a b lies beyond the focus/. From 
the terminal point a take two rays, a and d , the former a 
secondary axis, and therefore unrefracted, the latter par- 



24 


MEANS OF DIAGNOSIS. 


allel to the principal axis, and therefore passing after 
refraction through the principal focus /'. These two rays 
(and all others which pass through the lens from the point 
a) will meet at A, the conjugate focus of a. Similarly the 
focus of the point b is found, and the real inverted conju¬ 
gate image of a b is formed at A b. The relative sizes of 
a b and A b vary as their distances from the lens. 


Fig. 12. 



Real inverted image formed by a convex lens. 


If a b be so far off that its rays are virtually parallel on 
reaching the lens, its image A b will be at /', and very 
small. If a b be at /, its rays will become parallel after 
refraction, §§11 and 12, and form no image. If a b lies 
between/ or/' and the lens, the rays will diverge after 
refraction, and again will not form an image, see Fig. 10, 

c'T- 

But in the last two cases a virtual image is seen by an 
eye so placed as to receive the rays. In Fig. 13 two rays 
from a take after refraction the course shown by a and a , 
virtually meeting at A, see Fig. 10, vf ; and an observer 
at x will see at A b a virtual, magnified erect image of a b. 

The enlargement in Fig. 13 is greater the nearer a b is 
to/', and greatest when it is at/'. But as a b has no real 
existence, its apparent size varies with the known, or esti¬ 
mated, distance of the surface against which it is projected. 
A uniform distance of projection of about 12" (30 cm.) is 




OPTICAL OUTLINES. 


25 


taken in comparing the magnifying power of different 
lenses. 

When a b is at /', Fig. 13, we shall find on trial that the 
image A b can be seen well only by bringing the eye close 
up to the lens ; at a greater distance only part of the image 


Fig. 13. 



Virtual erect image formed by a convex lens. 


will be seen, and this part will be less brightly lighted. 
This is important in direct ophthalmoscopic examination. 
Thus in Fig. 14 an observer placed anywhere between 
the lens and x, receiving rays from every part of a b, will 
see the whole image. But if he withdraw to y, his eye 


Fig. 14. 



Virtual image ; result of observer varying distance of his eye from the lens. 


will receive rays only from the central part of a b, and 
will therefore not see the ends of the object. 

It is easily shown by similar constructions that the images 
formed by concave lenses are always virtual, erect, and dim in- 





2 6 


MEANS OF DIAGNOSIS. 


ishecl, whatever the distance of the object, Fig 15. Com¬ 
pare Fig. 11. 

17. The size of the image (whether real or virtual) varies 
with (1) the focal length of the lens, and (2) the distance 
of the object from the principal focus. 

Fig. 15. 


Image formed by a concave lens. 

(1) The shorter the focus of the lens, the greater is its 
effect or the “ stronger " it is ; the refractive power of a lens 
varies inversely as its focal length. 

(2) For a convex lens, the image, whether real or vir¬ 
tual, is larger— i. e., the effect greater—the nearer the 
object is to the principal focus, whether within or beyond ii. 

For a concave lens, the image is smaller— i. e., the effect 
greater—the further the object is from the lens, whether 
within or beyond the focus. 

18. Prisms. Any object viewed through a prism seems 
displaced toward the edge of the prism, and the amount of 
the displacement varies directly as the size of the refract¬ 
ing angle, §§ 5 and 6. The eye is directed toward the 
position which the object now seems to take, and this effect 
may be variously utilized: 1. To lessen the convergence of 
the visual lines without removing the object further from 
the eyes. In Fig. 16 the eyes, r and l, are looking at the 
object, oh, with a convergence of the visual lines repre¬ 
sented by the angle a. If prisms be now added with their 
edges toward the temples they deflect the light, so that it 
enters the eyes under the smaller angle ft, as if it had come 




OPTICAL OUTLINES. 


27 


from ob', and toward this point the eyes will be directed, 
though the object still remains at ob. The same effect is 
given by a single prism of twice the strength before one 


Fig. 16. 



Effect of prisms in lessening convergence. 


eye, though the actual movement is then limited to the eye 
in question. If spectacle lenses be placed so that the visual 
lines do not pass through their centres they act as prisms, 
though the strength of the prismatic action varies with the 
power of the lens and the amount of this “ decentration.’ > 

Table Showing the Prismatic Effect of Decentring 

Lenses (Maddox). 


Amount of Deeentration in Millimetres. 


Lens. 

1 D 



5 mm. 

17' 

10 mm. 

35' 

15 mm. 

52 / 

2 D 



35 

1° 

9 

1° 43 

3 D 



52 

1 

43 

2 

34 

4 D 



. 1° 10 

2 18 

3 

26 

6 D 



. 1 43 

6 

2G 

5 

9 

8 D 



. 2 18 

4 

35 

6 

50 






28 


MEANS OF DIAGNOSIS. 


In Fig. 17 the visual lines pass outside the centres of the 
convex lenses, a , and inside those of the concave lenses, b. 
Each pair therefore acts as a prism with its edge outward. 
2. To remove double vision caused by slight degrees of stra¬ 
bismus. The prism so alters the direction of the rays as to 
compensate for the abnormal direction of the visual line. 

Fig. 17. Fig. 18. 




Lenses acting as prisms. 


Diplopia removed by prism. 


In Fig. 18 r is directed toward x instead of toward ob, and 
two images of ob are seen, see Chapter XXI. The prism, 
p, deflects the rays to y, the yellow spot, and single binocu¬ 
lar vision is the result. 3. To test the strength of the ocular 
muscles. In Fig. 19 the prism at first causes diplopia by 
displacing the rays from the yellow spot, y y of the eye, R, 
see Chapter XXI. By a compensating rotation of the eye 
(cornea outward), shown in the figure by the change of 
the transverse axis from 1 to 2 , y is brought inward to the 
situation of im, the images are fused and single vision re¬ 
stored ; the effect of the prism is overcome by the action 




OPTICAL OUTLINES. 


29 


of the external rectus. This “ fusion power” of the sev¬ 
eral pairs of muscles may be expressed by the strongest 
prism that each pair can overcome. The fusion power of 
the two external recti is represented by a prism of about 
8°; that of the two internals by 25° to 50° or more; that of 
the superior and inferior recti, acting against each other, 
by only about 3°. 4. Feigned blindness of one eye may 

often be exposed by means of the diplopia, unexpected by 


Fig. 19. 



Prism used for testing strength of muscle. 

the patient, produced by a prism. The prism should be 
stronger than can be overcome by any effort— e. g., 8° or 
10°, base upward or downward. The patient is best thrown 
off his guard if the prism be held before the sound eye. If 
he now exclaims that he sees double, he must of course be 
seeing with both eyes. 

19. Refraction of the eye. The eye presents three refract¬ 
ing surfaces—the front of the cornea, 1 the front of the lens, 

1 The posterior surface of the cornea being parallel with the anterior 
causes no deviation, and the aqueous has the same refractive power as the 



30 


MEANS OF DIAGNOSIS. 


and the front of the vitreous; and in the normally formed 
or emmetropic eye (E.), with the accommodation relaxed, 
the principal focus, § 11, of these combined dioptric media 
falls exactly upon the layer of rods and cones of the retina 
— i. e., the eye in a state of accommodative rest is adapted 
for parallel rays. The point at which the secondary axial 
rays, see § 10, Fig. 8, cross, the “ posterior nodal point” 
n, Fig. 20, lies, in the normally formed eye, at 15 mm. in 
front of the yellow spot of the retina, and very nearly coin¬ 
cides with the posterior pole of the crystalline lens. The 


Fig. 20. 



Visual angle and retinal image. Ob, object; v, visual angle ; n, nodal point 
where the axial rays cross ; d, distance from n to the retina. The position of 
the retina in different states of refraction is shown by the three curved lines 
to the right, H. being represented by the line nearest to, and N. by the one 
furthest from, n, while the middle thin line shows the retina in E. 

angle included between the lines joining n with the ex¬ 
tremities of the object, ob, is the visual angle , v. If the 
distance, d , from n to the retina remain the same, the size 
of any image, Im, on the retina will depend on the size of 
the angle, v, and this again on the size and distance of ob. 
But if the distance, d, alters, the size of the image, Im, is 
altered without any change in v. Now the length of d 
varies with the length of the posterior segment of the eye; 
it is greater in myopia (M.) and less in hypermetropia (H.), 
and hence the retinal image of an object at a given dis- 


cornea. Hence the refractive effect of the cornea and aqueous together is 
the same as if the corneal tissue extended from the front of the cornea to the 
front of the lens. 



OPTICAL OUTLINES. 


31 


tance is, as the figure shows, larger in myopia and smaller 
in hypermetropia than in the normally formed eye. The 
length of d also varies with the position of n, and this is 
influenced by the positions and curvatures of the several 
refractive surfaces, n is slightly advanced by the increased 
convexity of the lens during accommodation, and much 
more so if the same change of refraction be induced by a 
convex lens held in front of the cornea: hence convex 
lenses, by lengthening d, enlarge the retinal image. Con¬ 
cave lenses put n further back, and, by thus shortening d, 
lessen the image. If the lens which corrects any optical 
error of the eye be placed at the “ anterior focus” of the 
eye, 1 13 mm., or half an inch, in front of the cornea, n 
moves to its normal distance (15 mm.) from the retina, 
whatever the length of the eye, and the images are there¬ 
fore reduced or enlarged to the same size as in the emme¬ 
tropic eye. For definition of astigmatism see Chapter XX. 

The length of the visual axis, a line drawn from the yellow 
spot to the cornea in the direction of the object looked at, 
is about 23 mm. The centre of rotation of the eye is rather 
behind the centre of this axis, and G mm. behind the back 
of the lens. The focal length of the cornea is 31 mm., and 
that of the crystalline lens varies from 43 mm. with accom¬ 
modation relaxed, to 33 mm. during strong accommodation. 

20. The apparent size of an object depends, in the first 
place, on the size of its retinal image , and this, as already 
shown, § 19, p. 30, depends upon (a) the size of the visual 
angle, and (6) the distance of the retina from the nodal 
point. It is clear that in Fig. 20 a smaller object placed 
nearer to the eye or a larger one placed further off might 
subtend the same angle as Ob, and therefore have a retinal 
image of the same size. There are, however, other factors 
contributing to our estimate of the size of objects, espe- 

i The anterior focus is the point where rays, which were parallel in the 
vitreous, are focussed in front of the cornea. 


32 


MEANS OF DIAGNOSIS. 


cially contrast of light and shade, estimation of distance, 
and effort of accommodation. 

A white object on a black ground looks larger than a 
black object of the same size on a white ground. The 
further off an object is judged to be, the larger does it 
look. 1 The greater the accommodative effort used, what¬ 
ever may be the distance of the object, the smaller does 
it appear; thus patients whose eyes are partly under 
the influence of atropine, and presbyopic persons whose 
glasses are too weak, complain that near objects, if looked 
at intently for a short time, become much smaller; while 
when one eye is under the action of eserine, causing spasm 
of the accommodation, objects appear larger than if held 
at the same distance from the other eye. Prisms with their 
bases toward the temples seem to diminish objects seen 
through them by necessitating excessive convergence of 
the eyes, the converse of Fig. 16. 

The optical conditions of clear sight are as follows: 

(1) The image must be clearly focussed on the retina— 
i. e., the retina must lie exactly at the focus of the rays 
which proceed from the object looked at; (2) it must be 
formed at the centre of the yellow spot, Chapter II., § 11 ; 
(3) it must have a certain size, and this is expressed by the 
size of the corresponding visual angle, v, Fig. 20; with 
good indoor light v must be equal to at least five minutes 
(y^th of a degree) in order that the form of the image may 
be perceived ; an object subtending any smaller angle, down 
to about one minute, is still visible, though only as a point 
of light ; 2 (4) the cornea, lens, and vitreous must be clear; 
(5) the illumination must be sufficient. Influence of the 
pupil: Other things being equal, the larger the pupil the 

1 In bright light, as in the open air, the mininmm visual angle is consid¬ 
erably less than 5 minutes. 

2 Apparent distance is also influenced by the color of the object. The 
chromatic aberration of the eye is said to afford the explanation; rays of dif¬ 
ferent refrangibilities being focussed on slightly different parts of the retina. 


OPTICAL OUTLINES. 


33 


worse is the sight, definition being lessened by the spherical 
aberration caused by the marginal part of the lens, Fig. 9. 
See “Artificial Pupil.” 

The smaller the pupil, the less is the spherical aberration 
(p. 30), and ccet. par., the better the V. Also the smaller the 
pupil the less is the accommodation needed for near vision. 
If the pupil be so small as to subtend an angle, “ angle of 
divergence,” of not more than five minutes with any point on 
the object, the object will be clearly seen without accommoda¬ 
tion. By calculation it appears that if the pupil had a diame¬ 
ter = 0.66 mm. it would subtend an angle of divergence of five 
minutes at about 0.5 m. (18") — i. e., with a pupil of 0.66 mm. 
print should, in good light, be clearly seen at 18" without any 
accommodation. That this is true may be proved by looking 
at fine print through a hole of the above size in a thin card 
held as close as possible to the eye. 

Numeration of spectacle lenses. Some system of num¬ 
bering is required which shall indicate the refractive power 
of the lenses used for spectacles. Two systems are current. 
In the first system, which was till lately universal, the unit 
of strength is a strong lens of 1" focal length. As all the 
lenses used are weaker than this, their relative strengths 
can be expressed only by using fractions. Thus, a lens of 
2” focus, being half as strong as the unit, § 17, 1, is ex¬ 
pressed as 1; a lens of 10” focus is y 1 ^; of 20” focus ^; 
and so on. The objections are, that fractions are inconve¬ 
nient in practice ; that the intervals between the successive 
numbers are very unequal; and that the length of the inch 
is not the same in all countries, so that a glass of the same 
number has not quite the same focal length when made by 
the Paris, English, and German inches respectively. 1 In 
the second system, which has almost displaced the old one, 
the metrical scale is used, the unit is a weak lens of 1 metre 


i 1" English = 25.3 mm., 1" French = 27 mm., 1" Austrian = 26.3 mm., 
1" Prussian = 26.1 mm. 


3 


34 


MEANS OF DIAGNOSIS. 


(100 cm.) focal length, known as a dioptre (D.), and the 
lenses differ by equal refractive intervals. A lens twice 
as strong as the unit, with a focal length of half a metre 
(50 cm.), is 2 dioptres (2 D.), a lens of ten times the 
strength, or one-tenth of a metre focus (10 cm.), is 10 D., 
and so on. The weakest lenses are 0.25, 0.5, and 0.75 D., 
and numbers differing by 0.5 or 0.25 D. are also introduced 
between the whole numbers. A slight inconvenience of 
the metrical dioptric system is that the number of the lens 
does not express its focal length. This, however, is obtained 
by dividing 100 by the number of the lens in D.; thus the 
focal length of 4 D. == = 25 cm. If it be desired to 

convert one system into the other, this can be done, pro¬ 
vided that we know what inch was used in making the lens 
whose equivalent is required in D. The metre is equal to 
about 37" French and 39" English or German ; a lens of 
36" French, No. 36 or ^ old scale, or of 40" English or 
German, No. 40 or -fo, is very nearly the equivalent of 
ID. A lens of 6" French (i = ¥ 6 g) will therefore be equal 
to 6 D.; a lens of 18" French (■Jg- = = 2 D., etc.; a 

lens of 4D. = i— i. e., a lens of 9" French, etc. 

The following lenses are used for spectacles, and are, 
therefore, necessary in a complete set of trial glasses. The 
first column gives the number in D., the second the focal 
length in centimetres, the third the approximate numbers 
on the French inch scale, the denominator of each frac¬ 
tion showing the focal length in French inches. It will be 
seen that some metrical lenses have no exact equivalents on 
the inch system. In the following table, and throughout 
the book, convex lenses are indicated, according to custom, 
by the + sign; concave lenses, by the — sign. 


OPTICAL OUTLINES. 


35 


1. 

D. 

(Dioptres.) 

2. 

Focal 
Length in 
cm. 

3. 

No. and 
Focal Length 
in Paris 
inches. 

1. 

D. 

(Dioptres.) 

2. 

Focal 
Length in 
cm. 

3. 

No. and 
Focal Length 
in Paris 
inches. 

- 

0.25 

400 


5 

20 

1 

T 

0.5 

200 

1 

7 2 

5.5 

18 

0.75 

133 

1 

TT1T 

6 

16 

l 

6 

1 

100 

3T 

7 

14 


1.25 

80 

A 

8 

12.5 

i 

4 

1.5 

66 

1 

2 4 

9 

11 

1 

4 

1.75 

57 

_1_ 

2 2 

10 

10 

i'A 

2 

50 

1 

TF 

11 

9 


2.25 

44 

1 

T6 

12 

8.3 

1 

T 

2.5 

40 

1 

1 4 

13 

7.7 


2.75 

36 

1 

1 3 

14 

7 

1 

2^ 

3 

33 

1 

1 2 

15 

6.7 

1 

2A 

3.5 

28 

1 

TO 

16 

6.2 

1 

2A 

4 

25 

1 

9 

18 

5.5 

1 

2 

4.5 

22 

1 

8 

20 

5 



Fig. 21. 



Trial-frame. 

To ascertain the refraction, the lenses are placed before 
the eye under examination in a trial-frame, Fig. 21. This 























































36 


MEANS 01 DIAGNOSIS. 


apparatus is constructed of metal, and is so arranged that 
the lenses are fitted into a series of grooves in a half-circle 
before the eye. For convenience in ascertaining the axis 
of the astigmatism the degrees are marked on a dial on 
the outer aspect of the half-circle containing the lenses. 

Prisms are numbered by their angle of refraction, which 
is (p. 22) about double the angle of deviation ; another 
method is to name the prism by the number of degrees of 
deviation which it produces; to indicate that degrees of 
deviation are meant the letter d should be used; thus 
prism 2° d indicates that the prism produces a deviation 
of 2° (Maddox). Prisms cannot be used as spectacles of 
a greater strength than about 4° d in each eye on account 
of the dispersion of light which they produce. 


CHAPTER II. 


EXTERNAL EXAMINATION OF THE EYE. 

It is very important that a systematic observation of all 
parts of the eye and its adnexa should be made in every 
case; and that nothing should escape his attention, the 
student is advised to accustom himself to observe some such 
plan of examination as the following: 

1. The Lids. —The appearance of the skin, the width of 
the palpebral fissure, and the condition of the edges of the 
lids and of the cilia should be carefully noted. The puncta 
should be examined; and if obstruction in the lachrymal 
passages be suspected, gentle pressure should be made over 
the sac with the finger, with a view to expressing any re¬ 
tained contents. 

2. The Conjunctival Cul-de-sac. —The degree of vascu¬ 
larity of the tarsal as well as of the bulbar mucous mem¬ 
brane should be ascertained, and the presence of granula¬ 
tions or abnormal secretion. The upper lid should be 
everted by the surgeon grasping the ciliary border with the 
thumb and index-finger of his left hand, while he depresses 
the upper edge of the tarsus with a probe or the forefinger 
of his right hand, the patient being requested to look fix¬ 
edly downward. 

3. The Eyeball. —The position of the globe in the orbit, 
and its size and relationship to the fellow eye, should be 
carefully noted. 

Exophthalmos ( proptosis) or protrusion of the eyeball: 
enlargement of the eyeball. Unequal prominence of the 
two eyes is best ascertained by seating the patient in a 

(37) 


38 


MEANS OF DIAGNOSIS. 


chair, standing behind him, and comparing the summits 
of the two cornea with each other, and with the bridge of 
the nose, or the line of the e) r ebrows. It can also be 
ascertained by placing the straight edge of a card from the 

Fig. 22. 



Method of holding the upper eyelid. (Wells.) 

eyebrow to the prominence of the cheek below the eye, and 
* measuring the distance of the cornea from the card on the 
two sides. The appearance of prominence or recession, as 
seen from the front, depends very much on the quantity 
of sclerotic exposed; thus, slight ptosis gives a sunken 
appearance to the eyes, and in slight cases of Graves’ dis¬ 
ease the proptosis seems to increase when the upper lids are 
spasmodically raised. It is to be remembered that real 
prominence of the eye may depend on enlargement of the 
eyeball—myopia, staphyloma, intraocular tumor—as well 
as on its protrusion, and that if only one eye be myopic 
the appearance will be unsymmetrical. Decided proptosis 
may follow tenotomy or paralysis of one or more ocular 
muscles. 

Enophthalmos, or retraction of the eyeball , sometimes 
follows wasting of the adipose tissue of the orbit, conse- 



Vessels of the front of the eyeball, c.m. Ciliary muscle. Ch. Choroid. 
Set. Sclerotic. V.V. Vena vorticosa, l. Marginal loop-plexus of cornea. 
Ant. and Post. Conj. Anterior and posterior conjunctival vessels. Ant. Cil. 
A. and V. Anterior ciliary arteries and veins. (Simplified and altered from 
Leber.) 

4. Information derived from the bloodvesssls visible on 
the surface of the eyeball. Three systems of vessels have 


EXTERNAL EXAMINATION OF THE EYE. 39 


quent upon se\eie blows with much extravasation of 
blood (see p. 32). In hypermetropia, in which the eye¬ 
ball is too short, and in the cases of paralysis of the cer¬ 
vical sympathetic, the eye often looks sunken. 


Fig. 23. 








40 


MEANS OF DIAGNOSIS. 


to be considered in disease; but most of them are too small 
to be easily seen in health. 1. The vessels proper to the 
conjunctiva, posterior conjunctival vessels , in which it is not 

Fig. 24. 




Conjunctival congestion (engorgement of the posterior conjunctival arteries 

and veins. (After Guthrie.) 

important to distinguish between arteries and veins, Fig. 
23, Post. Conj., and Fig. 24. 2. The anterior ciliary vessels, 

lying in the subconjunctival tissue; their perforating arte- 

Fig. 25. 

/ 


Congestion of the perforating branches of the anterior ciliary arteries. 
(Dalrymple.) The dusky spots at the seats of perforation are often seen in 
dark-complexioned persons. 

rial branches supply the sclerotic, iris, and ciliary body* 
their veins receive blood from Schlemm’s canal and the 
ciliary body. The perforating branches of the arteries , 




EXTERNAL EXAMINATION OF THE EYE. 41 


Fig. 23, A, are seen in health as several comparatively 
large tortuous vessels which stop short about T y' or 
from the corneal margin, Fig. 25; their very numerous, 
small, non-perforating (episcleral) branches are invisible 
in health, but form, when distended, a pink zone of fine, 
nearly straight, very closely-set vessels round the cornea, 
Fig. 23, a, and Fig. 26, “ ciliary congestion,” “ circum- 
corneal zone,” see Iritis and Diseases of Cornea; the per¬ 
forating veins are very small, but more numerous than the 
perforating arteries, Fig. 23, v, and their episcleral twigs 
form a closely-meshed network, Fig. 27. 3. The vessels 
proper to the margin of the cornea and immediately adja¬ 
cent zone of conjunctiva, anterior conjunctival vessels, and 
their loop-plexus on the corneal border, Fig. 23, l, and Fig. 
59; by these numerous minute branches, which are off¬ 
shoots of the anterior ciliary vessels, Systems 1 and 2 anas¬ 
tomose. 

Fig. 26. Fig. 27. 



** Ciliary congestion, ” engorgement Congestion of anterior ciliary 
of episcleral twigs of anterior ciliary veins, episcleral venous plexus, 
arteries. (After Dalrymple.) (After Dalrymple.) 


Speaking generally, congestion composed of (1) tortuous, 
bright brick-red vessels moving with the conjunctiva when 
it is slid over the globe, and least intense just around the 
cornea, Fig. 24, indicates a pure conjunctivitis, and is usu¬ 
ally accompanied by muco-purulent or purulent discharge. 
(2) A zone of pink congestion surrounding the cornea, and 




42 


MEANS OF DIAGNOSIS. 


formed by small, straight, closely set, parallel vessels, radi¬ 
ating from the cornea, and not moving with the conjunc¬ 
tiva, anterior ciliary arterial twigs, Fig. 26, points to irri¬ 
tation or inflammation of the cornea or iris. A more scanty 
zone of dark or dusky color, Fig. 27, which, when severe, 
is finely reticulated, episcleral venus plexus, often points to 
glaucoma, but may accompany other diseases, especially in 
old people. Congestion in the same region, more deeply 
seated, and of a peculiar lilac tint, especially if unequal in 
different parts of the zone, shows cyclitis or deep scleritis. 
(3) Congestion in the same zone also composed of small, 
superficially placed, bright red vessels, often encroaching 
a little on the cornea, anterior conjunctival vessels and loop - 
plexus of cornea, Fig. 59, shows a tendency to irritable cor¬ 
neal inflammation, which is often superficial. Localized 
or fasciculated congestion generally points to phlyctenular 
disease, Figs. 51 and 52. Although in the severe forms 
of all acute diseases of the front of the eye these types of 
congestion are usually mixed and but imperfectly distin¬ 
guishable, much information may often be derived from 
attention to the leading forms described. 

5. The Cornea.—It must be ascertained whether this mem¬ 
brane be transparent or clouded, and whether its curvature 
is regular. To detect irregularity of the corneal surface, 
the patient faces the window and follows with his eyes an 
object— e. y., the uplifted finger—held about 18" from him 
and moved slowly in different directions. The image of 
the window reflected from the cornea will become distorted 
or broken as it passes over any irregularity, such as an 
abrasion or ulcer. Loss of surface of the corneal epithe¬ 
lium may be easily demonstrated by placing a drop of a 
solution of fluorescin into the eye; this stains the surface 
from which the epithelium is removed, but leaves the rest 
of the cornea clear. Finer changes in the cornea are best 
studied by oblique illumination or by a lens of high mag- 


EXTERNAL EXAMINATION OF THE EYE. 43 


nifying power, such as a Hartnack, or through the binocu¬ 
lar magnifying lens of Jackson. 

The anterior chamber should be studied especially re¬ 
garding its depth and the presence of any exudate in it. 

6. The Iris.—The color of the iris should be compared 
with that of the fellow eye. Occasionally the two irides, 
although healthy, differ in color, one being blue or gray, 
the other brown or greenish ; more frequently a large sec¬ 
tor-shaped patch of dark color occupies part of the iris 
of one eye. Small pigmented spots are often seen on the 
iris. If the iris of an inflamed eye looks greenish, that of 
its fellow being blue, we should suspect iritis; and if the 
iris of a defective eye be different from its fellow, some 
morbid change should be suspected. Chapter VIII. 

7. The pupils are to be examined as to their equality, size 
in ordinary light, mobility, and form. The pupils are often 
large and inactive, and sometimes oval, in amaurotic 
patients, in glaucoma, and in paralysis of the circular 
fibres of the iris, supplied by the third nerve. They may 
be too large, though active, in myopia and in conditions of 
defective nerve-tone. Wide, recent dilatation of one pupil 
or both, with dimness of sight but without ophthalmoscopic 
signs of disease, is usually traceable to atropine or bella¬ 
donna, used by accident or design. When very small the 
pupil is seldom quite round. 

The size of the pupil is best obtained by the pupillome- 
ter devised by Hirschberg. This consists of a glass slide, 
which is graduated in millimetres, and has marked upon it 
in addition a series of circles ranging from 1 to 10 mm. in 
diameter. The instrument is held close to the eye under 
examination, and the circle readily found which corresponds 
to the diameter of the pupil. 

8. The Lens.—Opacities in the lens are often visible to 
the naked eye, but they are best studied by oblique illumi¬ 
nation or by the ophthalmoscope. The observer should 


44 


MEANS OF DIAGNOSIS. 


not be misled and suspect the presence of cataract by the 
gray reflex which is frequently emitted from senile lenses. 

The centre of the pupil usually lies a little to the nasal 
side of the corneal centre. 1 The pupils should be round, 
and, when equally lighted, equal in size. When one eye 
is shaded its pupil should dilate considerably, and on ex¬ 
posure contract quickly to its former size, direct reflex action ; 
during this trial the other pupil will act, but to a much less 
extent, indirect reflex action. The pupils contract when the 
gaze is directed to a near object (say 6" distant), i. e ., during 
accommodation and convergence, and dilate in looking 
at a distant object; but the range of this associated action 
is much less than that of the reflex action. The pupil 
dilates when painful impressions are made on the sensory 
nerves of the skin, e. g., by the faradic brush or by prick¬ 
ing with a pin. The pupils may be motionless to light and 
shade from iritic adhesions (Chapter VIII.) or from atrophy 
of the iris in glaucoma or other local disease; such condi¬ 
tions should be carefully noted or excluded. Reflex action 
is lost when the eyes are blind from disease of the optic 
nerves or retin se ; if only one eye be blind, the direct action 
of the pupil is lost in that eye, but (unless there be disease 
of the third nerve) its indirect action is much increased. 
When one eye is blind the pupil is often rather larger 
than that of the other. Reflex action may also be lost 
without any affection of sight, and without loss of associated 
action. Chapters XXI. and XXIII. 

Permanent inequality of the pupils without disease, either 
of eyes or of nervous system, is rare, but temporary dilata¬ 
tion of one pupil is not uncommon. When very active 
pupils are suddenly exposed after being shaded they often 
oscillate for a few seconds before settling, and finally re- 


1 This eccentricity varies in degree and exact position in different persons. 
Compare Irregular Astigmatism. 


EXTERNAL EXAMINATION OF THE EYE. 45 


main a little larger than at the first moment of exposure. 
Considerable differences in the action of the pupils, both in 
range and rapidity , are compatible with health ; in general, 
however, the pupils become smaller, and lose both in range 
and rapidity of action with advancing years ; atropine also 
often causes only partial dilatation in old people. Marked 
inactivity, with small size, should excite suspicion of spinal 
or cerebral disease (Chapter XXIII.). The pupils are 
smaller whenever the iris is congested, whether this be a 
merely local condition, e. g., in abrasion of cornea, or form 
part of a more general congestion, as in typhus fever 1 and 
in plethoric states, or be caused by venous obstruction, as 
in mitral regurgitation and bronchitis. They are large in 
ansemia, in conditions, such as aortic insufficiency, where 
the systemic arteries are badly filled, and during rigors; 
irritation of the sympathetic nerve in the neck is an occa¬ 
sional cause of mydriasis. Chapter XXI. 

9. The mobility of the eyeball may be impaired in any 
or every direction, and in any degree. Commonly only 
one eye is affected. First, to test the lateral and vertical 
movements, direct the patient with both eyes open to look 
successively toward, or follow a pencil or finger moved in, 
each of the four directions, up, down, right, and left; next, 
to test the power of convergence, he looks at the object held 
vertically in the middle line, rather below the horizontal, 
and gradually approached from 2' to about 6". In each 
position we must notice both eyes; thus, when the patient 
looks to his right we have to note the outward movement 
of his right and the inward movement of his left. The 
fixed marks for the inward and outward movements are 
the inner and outer canthi, and as the apparent range of 
movement judged in this way varies a little in different 

1 The small pupil of typhus and the frequently large pupil of typhoid are 
ascribed by Murchison to the differences in the vascularity of the iris in 
these diseases. Continued Fevers, p. 541. 


46 


MEANS OF DIAGNOSES. 


people, the corresponding movements of the two eyes 
should always be compared. In looking strongly outward 
the corneal margin does not in all persons quite reach the 
outer canthus, but it should always reach the inner can thus 
during inward rotation. In children and stupid people the 
movements are often defective from inattention. In very 
myopic eyes the movements are somewhat defective in all 
directions. The vertical movements are best shown by 
noting the position of the cornea in relation to the border 
of the lower lid; the border of the upper lid is less trust¬ 
worthy, since there may be some ptosis or other cause of 
inequality between the two sides. 

The range of movement of the eye, “field of fixation /’ or 
“field of direct vision/’ can be measured on the perimeter in 
the same way as the ordinary field of “ indirect vision.” The 
test-object, e. g., a word of small print, moved along the vari¬ 
ous meridians from the centre toward the periphery, is fol¬ 
lowed by the eye under examination until it can no longer be 
read— i. e., until the visual axis can no longer be directed to it. 
A coarse test-object would be recognized by parts of the retina 
away from the yellow spot, and must, therefore, not be used. 
In this way it is found that the normal range of movement of 
the eye extends through about 45° in each direction from the 
centre. The state of mobility of the eye, and the progress, in 
cases of ocular paralysis, may be accurately recorded in this 
way. 1 

10. To estimate the tension of the eyeball (T.), the patient 

looks steadily down, and gently closes the eyelids; the ob¬ 
server then makes light pressure on the globe through the 
upper lid, alternately with a finger of each hand as in try¬ 
ing for fluctuation, but much more delicately. The finger¬ 
tips are placed very near together, and as far back over 
the sclerotic as possible, not over the cornea; The pressure 

1 For further details consult a paper by Landolt in Trans. Internat. Med. 
Congress, London, 1881, vol. iii. p. 25. 


EXTERNAL EXAMINATION OF THE EYE. 47 


must be gentle, and be directed vertically downward , not 
backward. It is best for each observer to keep to one pair 
of fingers, not to use the index at one time and the middle 
finger at another. Patient and observer should always be 
in the same relative position, and it is best for both to 
stand and face one another. Always compare the tension 
of the two eyes. Be sure that the eye does not roll upward 
during examination, for if this occur a wrong estimate of 
the tension may be formed. Some test both eyes at once 
with two fingers of each hand. Normal tension is expressed 
by T. n. Recognizable increase and decrease are indicated 
by the -(-or — sign, followed by the figure 1, 2, or 3. Thus 
T. -f- 1 means decided increase; T. + 2, greater increase, 
but the eye can still be indented; T. -4- 3, eye very hard, 
cannot be indented by moderate pressure ; T.— 1 — 2 — 3 
indicate successive degrees of lowered tension. A note of 
interrogation (T. ? -f- or ?—) for doubtful cases, and T. n. 
for the normal, give nine degrees which may be usefully 
distinguished. Even good observers sometimes differ as 
to the minor changes of tension. Apart from variations 
in delicacy of touch it is to be remembered that eyes deeply 
set in the orbits are more difficult to test, and that T. in a 
few cases really does change at short intervals— e. g., within 
half an hour. Increase in the rigidity of the sclerotic, 
which often occurs in old age; or in its thickness, as the 
result of disease, may increase the apparent tension, though 
the internal pressure may be normal or even too low. 
When an eye contains bone it feels like wood covered 
with wash-leather. 1 

The student has proceeded thus far without the aid of 
instruments other than a convex spherical lens. To com¬ 
plete the functional examination of the eye it is necessary 

i 4 

i Plates of bone, sometimes joined so as to form a cup, are not uncommonly 
found on the inner (retinal) surface of the choroid in eyes which have been 
long blind from iridochoroiditis. 


48 


MEANS OF DIAGNOSIS. 


to have recourse to more or less complicated apparatus. It 
has become the custom in America, at this stage of the ex¬ 
amination, to seat the patient in front of a phorometer, Fig. 
28. This is an instrument especially constructed to measure 
the relative strength of the ocular muscles. In addition to 
a Maddox rod (see page 51) and rotary prisms which are 
placed before each eye for this purpose, the instrument is 
provided with cells to carry test-lenses, so that the refrac¬ 
tion of the eye may be determined without the employment 


Fig. 28. 



of the old-fashioned trial-frame. The first step in the ex¬ 
amination is the determination of the acuteness of vision. 

11. Testing the acuteness of sight. By acuteness of sight 
(Y.) is meant the power of distinguishing/orm, and, as com¬ 
monly used, the term refers only to the centre of the visual 
field, the peripheral part of the retina having a very im¬ 
perfect power of distinguishing form and size. Y. varies 
considerably in different persons whose eyes are normal. It 
is said to diminish somewhat in old age, without disease 
of the eyes (Donders). The standard taken as normal is 
the power of distinguishing square letters that subtend a 
visual angle of five minutes, Fig. 20 and p. 31, the limbs 
of which are of uniform thickness, each limb subtending 
an angle of one minute (Snellen’s Test Types). The types 

























































EXTERNAL EXAMINATION OF THE EYE. 49 


are made of various sizes, each being numbered according 
to the distance, in feet or metres, at which it subtends a 
visual angle of five minutes. Thus, No. 6 subtends this angle 
at 6 in., No. 3 at 3 m., No. 1 at 1 m., etc. Numerically, 
acuteness of vision is expressed by a fraction, of which the 
denominator is the number of the type D, and the numer¬ 
ator the greatest distance (d) at which it can be read, 
Y = |: if No. 6 is read at 6 m. * =% or 1— i. e., Y is nor¬ 
mal ; if only No. 18 can be read at 6 m. ^ = T 6 g ; if only 
60, then - d =-§-$. Any distance greater than about 3 m. 
may be selected for this test— i. e., No. 3 read at 3 m., or 
No. 5 at 5 m., generally shows the same acuteness as No. 
6 read at 6 m. But at distances less than 3 m. the accom¬ 
modation comes into play, and the illumination is often 
brighter; hence No. 1 at 1 m. (1) does not necessarily show 
the same state of sight as No. 6 at 6 m. (£). It is there¬ 
fore best, by recording the fractions unreduced, to indicate 
the distance at which the test was used. For testing near 
vision, Snellen’s types are thought by some to be practi¬ 
cally inferior to those of Jaeger and others, in which the 
letters have the form and proportions found in ordinary 
type. See Appendix. If V. be very bad (less than g 6 Q or 
Jq), it may be expressed accurately enough by noting the 
distance at which the outspread fingers can be counted 
when exposed to a good light and against a dark back¬ 
ground. Below this point we can still distinguish good 
from bad, or uncertain, perception of light and shade (p. 
1 .), by alternately exposing and shading the eye with the 
hand, without touching the face. 

In using the test types it is necessary to insure that the 
illumination shall not fall below a certain level; it has 
been found by Snellen that if it be reduced below 20 metre 
candles 1 the acuteness of vision rapidly declines. Each 
eye should be tested separately. 

i Strictly from a point about in front of the cornea, since the glass 
cannot be placed upon the eyeball. 


4 


50 


MEANS OF DIAGNOSIS. 


12. Accommodation (Acc.) is tested clinically by meas¬ 
uring the nearest point (pundum proximum , p .) at which 
the smallest readable type (Snellen’s 0.5 or Jaeger’s 1) can 
be clearly seen. This type being carried in a bracket 
on an arm of the phorometer, which is graded in centi¬ 
metres. The region of accommodation is the space in 
which it is available, see Presbyopia. The amplitude , 
power, or range of Acc. is expressed in terms of the convex 


Fig. 29. 



Accommodation represented by a convex lens. 


lens, whose focal length = the distance from the cornea 1 to 
p., this being the lens which adapts V. in an eye without 
Acc. from the farthest point of distinct vision ( punctum 
remotissimum, r.) to p. Thus in Fig. 29 let p. be at 10 
cm. ; if Acc. be then relaxed, i. e., the eye be adapted 
for parallel rays, the rays from p. will be focussed at 
C. F., behind the retina; but V. will again be clear at 
10 cm. if a lens, l, of 10 cm. focus (= 10 D., see p. 42) 
be held close to the cornea; because the rays from p will 
be made parallel by l before entering the eye (Chapter 
I., §§ 11 and 12), and will therefore be focussed on the 
retina. 

Convergence of the visual axes upon a point at any 
given distance is usually associated with accommodation 
for the same distance. The two functions can, however, 

1 A metre candle (m.c.) is the light given by a standard candle at one metre 
distance (Snellen: Bowman Lecture, 1896). 



EXTERNAL EXAMINATION OF TIIE EYE. 51 


be somewhat dissociated to an extent that varies with age 
and in different persons; i. e., Ace. can be either relaxed 
a little or increased a little, without changing any given 
degree of convergence; this independent portion is known 
as the relative accommodation. 

13. Balance of External Eye Muscles.—The purpose of 
the various tests for the determination of ocular muscle 
balance is to destroy the desire to fuse the retinal images 
in both eyes by changing the image of one eye. This is 
best accomplished by means of the Maddox rod, Fig. 
30, which consists of a series of rods of glass conveniently 


Fig. 30. 



adjusted in a metallic disc, and so adjusted in the phorom- 
eter employed by the Editor that it may be rotated into 
the vertical and horizontal positions with great accuracy. 

The patient is seated before the phorometer, and is told 
to regard a small point of light or a candle-flame 5 m. 
awav. The rod is then swung into a vertical position 
before the eye with best vision ; and if the horizontal streak 
of light which is projected upon the retina by means of 
the cylindrical action of the rod passes through the unal¬ 
tered flame seen by the other eye, there is said to be ver¬ 
tical muscle balance, or orthophoria; if, on the other hand, 
























































52 


MEANS OF DIAGNOSIS. 


the streak deviates higher or lower than the light, the con¬ 
dition is designated as hyperphoria , or the tendency of one 
visual axis to turn above the other. The rod is now turned 
into the horizontal axis, and a vertical streak obtained. 
Should this pass through the flame, lateral orthophoria is 
said to exist. Should, however, the streak be displaced 
toward the same side as that before which the rod is held, 
convergence of the visual axes, or esophoria, is said to be 
present; exophoria, or divergence of the visual axis, when 
the streak is on the opposite side. 

The degree of the heterophoria, the term used to express 
any latent ocular deviation, is measured by the prism 
required to bring the images into the normal relations of 
orthophoria. 1 

The Maddox test for the reading distance consists in 
placing a prism of 8° base up or down before one eye, 
while the gaze is directed at an arrow, printed on a card 
which is adjusted on the arm of the phorometer at 40 
cm. from the eyes, the degree of the deviation produced by 
the prism being readily ascertained by rotary prisms before 
the eyes. 

Having ascertained the latent deviations, it now becomes 
necessary to measure the strength of the eye muscles in rotat¬ 
ing the eyes. For this purpose the eyes are directed toward 
the flame, which is still held at their level, 5 m. distant, 
and the rotary prisms swung into position before the eyes, 
with their bases in. They are then slowly rotated until the 
patient sees two flames, when the reading of the prism is 
noted and the power of the rectus extend— i. e., the abduct¬ 
ing power—elicited. The prisms are then rotated so that 
their bases are out, and the reading of the prisms noted 
when double vision is once more obtained, eliciting the 

1 Esotropia and exotropia are names which have been introduced by 
Stevens to designate actual deviations of the eyes, and to replace the older 
terms of convergent and divergent strabismus respectively. 



EXTERNAL EXAMINATION OF THE EYE. 53 

adducting power, or that of the rectus interni. To ascer¬ 
tain the strength of the vertical muscles, supra and infra 
duction, the prisms are rotated into vertical positions. 

It has been found after many observations that normally 
abduction ranges from 6° to 8°, adduction from 16° to 
30°, and supra and infra duction from 2° to 3°. If these 
ratios do not obtain in any given case, lieterophoria un¬ 
doubtedly exists. 

14. The Ophthalmometer.—This instrument has been 

Fig. 31. 


devised to obtain the measurements of the radius of curva¬ 
ture of the cornea, and consists of a telescope mounted 












54 


MEANS OF DIAGNOSIS. 


upon a tripod, which can be moved laterally, higher or 
lower or backward or forward, to obtain the proper focus 
of the observed eye. The cornea is viewed through a 
double refracting prism contained in the telescope, which 
produces a double image, and the measure of the displace- 
ment which occurs after the strength of the prism has been 
altered sufficiently to bring the images into contact, and 
correspondingly to the size of the corneal image, represents 
the amount of the astigmatism. The amount and axis of 
the corneal astigmatism may be usually accurately obtained 
by means of this instrument, but glasses should never be 
prescribed from it to the exclusion of the final test— i. e., 
the trial-lenses. 

15. The field of vision (F) (properly, of indirect vision ) 
is the entire surface from which, at a given distance, light 
• reaches the percipient part of the retina, the eye being 
stationary, Fig. 32. If each part of the field be equidis¬ 
tant from the part of the retina to which it corresponds, 
the field will be hemispherical, with its inner or concave 
surface toward the eye; it may, however, be projected on 
to a flat surface, and for many clinical purposes this is suffi¬ 
cient. For roughly testing the field— e. g., in a case of 
chronic glaucoma, or of atrophy of optic nerve, or of hemi¬ 
anopsia—the following is generally enough. Place the 
patient with his back to the window; let him cover one 
eye, and look steadily at your eye or nose, as a centre, 
from a distance of 18" or 2'. Then hold up your hands with 
the fingers spread out in a plane with your face, and ascer¬ 
tain the greatest distance from the central point at which 
they remain visible when moved in various directions—up, 
down, in, out, and diagonally. The patient must look 
steadily at the face, and not allow his eye to wander after 
the moving fingers. 

A more exact method is to make the patient gaze, with 
one eye covered, at a white mark (the “ fixation spot”) 


EXTERNAL EXAMINATION OF THE EYE. 55 

on a large blackboard at a distance of 12" or 18", and to 
move a piece of white chalk set in a long black handle, 
from various parts of the periphery toward the fixation 
spot, until the patient exclaims that he sees something 
white. If a mark be made on the board at about eight 
such peripheral points, a line joining them will give, with 
fair accuracy, the boundary of the visual field if this be 
not larger than 45° in any direction ; but beyond that 
angle the object, if on a flat surface, will be much too far 


Fig. 32. 



Field of vision with radius of 12", projected up to 45° on to a flat 
surface two feet square. F, fixation spot. 


from the eye to make the test accurate, see Fig. 32. A 
true map, unless the field be much contracted, can be 
made only by means of an instrument, the perimeter, see 
appendix for description of, which consists essentially of 
an arc marked in degrees, and movable around a central 
pivot on which the patient fixes his gaze. Thus meas¬ 
ured the field covers a somewhat oval portion of the 
hemisphere, the smaller end being upward and inward, 
Fig. 33. From the fixation point it extends 90° or more 
in the outward direction, but only about 65° or rather less 




56 


MEANS OF DIAGNOSIS. 


Fig. 33. 



Field of vision of right eye as projected by the patient on the inner surface 
of a hemisphere, the pole of which forms the object of regard (half-diagram¬ 
matic). T, temporal; N, nasal side, w, boundary for white; b, for blue; 
r, for red ; g. for green. (Landolt.) 


Fig. 34. 



Binocular field of vision. The white part is the portion common to the two 
eyes— i. e., possessing binocular vision ; the shaded (temporal) part shows the 
portion in which binocular vision is wanting. F. Fixation point. The two 
blind spots are marked by round spots. (Simplified, after Forster.) 





































EXTERNAL EXAMINATION OF THE EYE. 57 


inward, upward, and downward. The visual fields of the 
two eyes overlap only at their inner and central parts, so 
that binocular vision is impossible in the outer part of the 
field, Fig. 34. 

16. Color perception is best expressed by the power of dis¬ 
criminating between various colors without naming them. 
The best test-objects are a series of skeins of colored wool, 
or, for pocket use, smaller strips of colored paper, or col¬ 
ored stuffs. A color-blind person will expose his defect by 
placing together, or “ confusing ” as similar, certain colors, 
usually mixed tints, which to the normal eye appear quite 
different. The set of wools now in common use was intro¬ 
duced by Prof. Holmgren, of Upsala. See Appendix. Ac¬ 
quired color-blindness, from atrophy of the optic nerves, 
may often be detected quite well by asking the names, if 
the patient has been well trained in colors. But for the 
congenitally color-blind the “ confusion test,” without 
names, is far better; first, because such persons can often 
distinguish ordinary colored objects from one another by 
differences of shade — i. e., by differences in the quantity 
of white light which they reflect, and hence they escape de¬ 
tection unless tested with a large series of different colors 
in many shades, some of which shades, containing equal 
quantities of white, will look, to them, exactly alike; and, 
secondly, though such persons often use the names for colors 
freely, the words do not convey the same meaning to them 
as to those with normal color sense, and hopeless confusion 
results from an examination so made. For details, see 
Chapter XV. and Appendix. 


CHAPTER III. 


EXAMINATION OF THE EYE BY ARTIFICIAL LIGHT. 

This includes (1) examination by focal or oblique light; 
(2) examination by the ophthalmoscope. 

1. Examination by Focal or Oblique Light. 

In using focal, oblique, or lateral illumination the anterior 
parts of the eye are examined with the light of a lamp 
concentrated by a convex lens. The method is used to 
detect or examine opacities of the cornea, changes in the 
appearance of the iris, alterations in the outline and area 
of the pupil from iritis, and opacities of the lens. Such 
an examination is to be made by routine in every case 
before using the ophthalmoscope. We require a somewhat 
darkened room, a convex lens of two or three inches focal 
length, one of the large ophthalmoscopic lenses, and a 
bright, naked lamp-flame. 

The patient is seated with his face toward the light, 
which is at about 2' distance. The lens, held between the 
finger and thumb, is used like a burning-glass, being placed 
at about its own focal length from the patient’s cornea, and 
in the line of the light, so as to throw a bright pencil of 
light on the front of the eye at an angle with the obser¬ 
ver’s line of sight. Thus all the superficial media and struc¬ 
tures of the eye can be successively examined under strong 
illumination, the distance of the lens being varied a little, 
according as its focus is required to fall on the cornea, the 
iris, or the anterior or posterior surface of the crystalline 
(58) 


EXAMINATION OF EYE BY ARTIFICIAL LIGHT. 59 


lens, Fig. 35. By varying the position of the light and of 
the patient’s eye, making him look up, down, and to each 
side, we can examine all parts of the corneal surface, of 
the iris, of the pupillary area— i. e., the anterior capsule of 
the lens, and of the lens substance. If the light be thrown 
at a very acute angle on the cornea or lens, opacities are 


Fig. 35. 



Focal illumination. 


much more visible than if it fall almost perpendicularly. 
By habitually magnifying the illuminated parts by a second 
lens held in the other hand, much additional information 
can be gained. 

For complete exploration of all parts of the crystalline 
lens the pupil must be dilated with atropine, but careful 



GO 


MEANS OF DIAGNOSIS. 


examination without atropine will generally enable us to 
detect opacities lying in or near the axis of the lens even 
if deeply seated. In examining the posterior pole of the 
lens the light must be thrown almost perpendicularly into 
the pupil, and the observer must place his eye as nearly in 
the same direction as is possible without intercepting the 
incident light. Opacities of the cornea and anterior layers 
of the lens appear whitish, deep opacities in the lens, espe¬ 
cially in old people, look yellowish, by focal light. Tumors, 
large opacities in the vitreous, and retinal detachments 
may be seen by this method if they lie close behind the 
lens. Minute foreign bodies in the cornea will often be 
seen by focal light when invisible, because covered by hazy 
epithelium, in daylight. 

2. Ophthalmoscopic Examination. 

The ophthalmoscope enables us to see the parts of the 
eye behind the crystalline lens, by making the observer’s 
eye virtually the source of illumination for the observed 
eye. Rays of light entering the pupil in a given direction 
are partly reflected back by the choroid and retina, and on 
emerging from the pupil take the same or very nearly the 
same course that they had on entering (§ 12, p. 22). Hence 
the eye of the observer, if so placed as to receive these 
returning rays, must also be so placed as to cut off the 
entering rays; as, therefore, no light can enter in the 
necessary direction, none can return to the observer’s eye. 
This is why the pupil is usually black. Although with a 
large pupil, especially in a hypermetropic or myopic eye, 
the observer receives some of the returning rays, because 
he does not intercept all the entering light, and in this way 
sees the pupil of a fiery red instead of black, still for any 
useful examination the observer’s eye must, as already 
stated, be in the central path of the entering and emerg- 


EXAMINATION OF EYE BY ARTIFICIAL LIGHT. 01 


o *<■ ^ is gained by looking through a small 

hole in a mirror, by which light is reflected into the 
patient’s pupil, and this perforated mirror is the ophthal¬ 
moscope. There are two ways of seeing the deep parts of 
the eyeball by this means. 

1. The indirect method of examination, by which a clear, 
real, inverted image of the fundus, somewhat magnified, 
is formed in the air between the patient and the observer. 

The fundus of the eye seen on this principle is magnified 
about five diameters, if the eye be normal. The image is 
larger in h and smaller in m. Notice that if the obser¬ 
ver’s head be moved slightly from side to side, the image 
will appear to move in the opposite direction. 

2. The direct method of examination, by which, except 
when the eye is myopic, a virtual erect image is seen, more 
magnified than in the former method and situated behind 
the patient’s eye. 

The emmetropic eye, with the accommodation fully re¬ 
laxed, is adjusted for distant objects - i. e., parallel rays, and 
receives a clear image of such objects on the layer of rods 
and cones of the retina (p. 30). A clear image of the 
fundus of the eye—i. e., the retina, optic disk, and choroid, 
can be obtained in such an eye on condition that the eyes, 
both of patient and observer, be adjusted for infinite dis¬ 
tance— i. e., for parallel rays; in other words, that the 
accommodation of both be relaxed. The fundus so seen 
is magnified about 20 diameters. 

In order to use the ophthalmoscope 1 it is first necessary 
to learn to manage the mirror and light. 1. Seat the 
patient in a darkened room and place a lamp with a large, 
steady, naked flame on a level with his eyes, a few inches 
from his head, and about in a line with his ear. The lamp 
may be on either side, but is usually placed on his left, and 


1 For choice of instruments see Appendix. 


G2 


MEANS OF DIAGNOSIS. 


it is better to keep to the same side until practice has given 
steadiness to the various combined movements which are 
necessary. 2. Sit down in front of the patient with his 
face fronting your own, feature to feature. It is most con¬ 
venient for the observer’s face to be a little higher than 
that of the patient. 3. Take the mirror of the ophthal¬ 
moscope, without any lens behind, and without the large 
lens, in your left hand for examining the patient’s left eye, 
and vice versa for his right eye, hold it, mirror toward the 
patient, close to your own eye, and with the sight-hole 
placed so that with your other eye closed you see the 
patient through it. Now rotate the mirror slightly toward 
the lamp until the light reflected from the flame is thrown 
into the patient’s pupil, and open your other eye. 4. You 
will so far have seen nothing except the front of the 
patient’s eye, unless atropine have been used, for he will 
have looked at the centre of the mirror, and his pupil, 
strongly contracted, will look either black or very dull 
red. 5. Now tell him to look steadily a little to one side, 
into vacancy, or at an object on the other side of the room. 
The pupil will now become red—bright fiery red if it be 
rather large; a duller red if it be small or the patient’s 
complexion be dark. In one position, when the eye under 
examination looks a little inward, the red will change to a 
yellowish or whitish color, and this indicates the position 
of the optic disk. 6. Learn to keep the light steadily on 
the pupil, during slow movements backward and forward 
and from side to side, taking care that the patient keeps 
his eye all the time in the same position, and does not 
follow the movements of the mirror; the test of steadiness 
will be that the pupil remains of a good red color in all 
positions. Up to this point the examination may be made 
without atropine; and so far only a uniform red glare will 
have been seen, no details of the fundus being visible, unless 
the patient be either myopic or considerably hypermetropic. 


EXAMINATION OF EYE BY ARTIFICIAL LIGHT. 03 



Ophthalmoscopic examination by the “ indirect method.” The thick lines r r', rays from the lamp, are reflected from 
the mirror to, in the directions r' r", traverse the lens l , and are focussed in front of the retina ob, on which they therefore 
throw a diffused light. From the fundus thus lighted, pencils of rays, shown by thin lines, are given off, which emerge 
from the eye parallel and form a clear inverted image, im, at the focus of the lens l ; this image is viewed through the 
sight-hole by the observer obs. The distance between obs and im is about 10", and from im to a about 5". 





64 


MEANS OF DIAGNOSIS. 


In order to see the details of the fundus it is best to 
begin by learning the “ indirect method,” Fig. 36, for, 
though rather less easy, it is more generally useful than 
the direct. 

Take the mirror without any lens behind it in one hand, 1 
and one of the large convex “objective” lenses corre¬ 
sponding to l in the other. Always, if possible, have the 
pupil dilated with atropine, for by this means you learn to 
see the fundus much more quickly and easily. In exam¬ 
ining the patient’s right eye, apply the mirror with your 
right hand to your right eye, holding the lens in your left 
hand; it is best to reverse everything for his left eye, but 
the position of the light need not be changed. The hand 
which carries the lens should be steadied by resting the 
little or ring-finger against the patient’s brow or temple. 

We usually begin by looking for the optic disk, which 
is one of the most important and easily seen parts. As 
the disk lies to the nasal side of the posterior pole of the 
eye, the cornea must be rotated a little inward— i. e., the 
back of the eye outward, in order to bring the disk oppo¬ 
site the pupil, when the observer is immediately in front; 
the right eye, e. g., must be directed to the observer’s right 
ear, or to the uplifted little finger of his mirror hand. The 
patient must turn his eye, not his head, in the required 
direction. The lens should be held about 2"-3", and the 
observer’s eye be about 15”, from the patient’s eye; the 
image of the fundus being formed in the air 2” or 3" in 
front of the lens will thus be situated about 10" from the 
observer. 

The bright red glare, from the choroid , will be obvious 
enough; but most beginners find some difficulty in avoid- 

1 But many learn to see the image more quickly and easily by placing a 
convex lens of 4 D. behind the mirror. If the observer wears glasses for 
reading he should wear them, or put a lens of the same strength behind the 
mirror, for the indirect examination. 


EX AMIN A TION OF EYE BY ARTIFICIAL LIGHT. 65 


ing the reflection of the light from the patient’s cornea, 
and in adjusting the accommodation and the distance of 
the head, so as to see the image clearly. The head must 
be slowly moved a little further from or nearer to the 
patient, and at the same time an attempt made to adjust 
the eyes, both being kept open, for a point between the 
observer and the lens. As a rule, the disk and retinal 
vessels are seen clearly at the first sitting. 

The optic disk —ending of the optic nerve in the eye 
above the lamina cribrosa, optic papilla, Figs. 37 and 39— 
is round, well defined, much lighter in color than the fiery 
red of the surrounding fundus, and numerous bloodvessels 
are seen to radiate from its centre, chiefly upward and 
downward. As soon as the disk can be easily seen the 
student must pass on to the study of the most important 
details of this part itself, and of the other parts of the 
fundus. Some of these will be described here and others 
in the chapters on Diseases of the Choroid and Retina, and 
on the Errors of Refraction. 

The disk, as a whole, is grayish-pink in color with an 
admixture of yellow. It is nearly circular, but seldom per¬ 
fectly so, being often apparently oval or slightly irregular. 
Two differently colored parts are noticeable—a central 
patch, whiter than the rest, into which most of the blood¬ 
vessels dip; and a surrounding part of pink or grayish- 
pink. In many eyes, especially in old persons, we distin¬ 
guish a third part, a narrow boundary line of lighter color, 
which represents the border of the sclerotic, sceleral ring , 
Fig. 37. The bloodvessels consist of several large trunks 
and a varying number of small twigs; the large trunks 
emerge from the central white part of the disk, and often 
bifurcate once or twice on its area; the small twigs may 
emerge separately from various parts of the disk, or form 
branches of the large trunks. 

Variations. The color of the disk appears paler or 

5 


66 


MEANS OF DIAGNOSIS. 


darker according to the color of the surrounding choroid, 
the brightness of the light used, and the patient’s age and 
state of health. A curved line of dark pigment often 
bounds a part of the circumference of the disk, Fig. 39, 
and has no pathological meaning. The central white patch 
varies greatly in size, position, and distinctness; it may be 
so small as hardly to be perceptible, or very large; may 
shade off gradually or be abruptly defined ; may be central 
or eccentric; when large it generally shows a grayish stip¬ 
pling or mottling, Fig. 39. This central white patch repre¬ 
sents a hollow, the physiological cup or pit, compare Figs. 
39 and 40, left by the nerve-fibres as they radiate out from 


Fig. 37. 



Ophthalmoscopic appearances of healthy fundus in a person of very fair 
complexion. Scleral ring well marked. Left eye, inverted image. (Wecker 
and Jaeger.) 


the centres of the disk toward the retina, like the tentacles 
of an open sea-anemone; and through it the chief blood¬ 
vessels pass on their way between the nerve and the retina. 
This depression is generally shaped like a funnel or a dimple, 


















EXAMINATION OF EYE BY ARTIFICIAL LIGHT. G7 


with gradually sloping sides, Fig. 40; but sometimes the 
sides are steep, or even overhanging; in other eyes it is 
wide, shallowed and enlarged toward the outer side of the 
disks. The physiological pit is whiter than the rest of the 
disk, because the grayish-pink nerve-fibres are absent at 
this part, and we can therefore see down to the opaque, 
white, fibrous tissue which, under the name of lamina cri- 
brosa , forms the floor of the whole disk, Fig. 39. The 
stippled appearance often noticed in the pit is caused by the 
holes in this lamina, through which the bundles of nerve- 
fibres pass on their way to the retina; the holes appear 
darker because filled by non-medullated nerve-fibres, which 
reflect but little light. 

The other parts of the fundus. The groundwork is of a 
bright fiery red—the choroid, not the retina; in many eyes 
this color is nearly uniform, but in persons of very light 
or very dark complexion we see a pattern of closely set, 
tortuous, red bands (vessels of the choroid), separated by 
spaces either darker or of lighter color, Fig. 37. For 
details see Chapter XII. 

Upon this red ground the vessels of the retina divide 
and subdivide dichotomously. It will be noticed that the 
chief trunks pass almost vertically upward and downward, 
and that no large branches go to the part apparently inward 
from the disk—-to the left in the figure; that the visible 
retinal vessels are comparatively few and are widely spread ; 
that they become progressively smaller as they recede from 
the optic disk; and that they never anastomose with each 
other. Special attention must be given to the part, appar¬ 
ently to the inner, nasal, side of the optic disk, really to 
its outer, temporal side—which is the region of most accu¬ 
rate vision, the yellow spot, y. s., macula lutea, or shortly, 
“ macula.” In this region, which comes into view when the 
patient looks straight at the ophthalmoscope, the choroidal 
red is duller and darker than elsewhere. It is skirted by 


68 


MEANS OF DIAGNOSIS. 


large retinal vessels which give off numerous twigs toward 
its centre, though none of them can be seen quite to reach 
that point; compare Fig. 88, Chapter XIII. In many 
eyes nothing but these indefinite characters mark the 
y. s.; but in some, especially in dark eyes and young 
patients, a minute bright dot occupies its centre, and is 
encircled by an ill-bounded dark area, around which again 
a peculiar, shifting, white halo is seen. The minute dot is 
the fovea centralis , the thinnest part of the retina. The 
neighborhood of the disk and y. s. forms the central region 
of the fundus. The peripheral parts are explored by tell¬ 
ing the patient to look successively up, down, and to each 
side, without moving his head. To see the extreme periph¬ 
ery the observer must move his head as well as the patient 
his eye. Toward the periphery the choroidal trunk-vessels 
are often plainly visible even when none are distinguishable 
at the more central parts. 

The vessels of the retina are easily distinguished from 
those of the choroid by their course and mode of branch¬ 
ing; by the small size of all except the main trunks; by 
their sharper outline and clearer tint; but especially by 
the presence of a light streak along the centre of each, 
Fig. 37, which gives them an appearance of roundness, 
very different from the flat, band-like look of the cho¬ 
roidal vessels. They are divisible into two sets : a darker, 
larger, somewhat tortuous set—the veins; and a lighter, 
brighter red, smaller, and usually straighter set—the arte¬ 
ries ; the diameter of corresponding branches being about 
as 3 to 2. The arteries and veins run pretty accurately 
in pairs. Pressure on the eyeball, through the upper lids, 
causes visible pulsation of the arteries on the disk. 

The indirect method of examination is most generally 
useful, because it gives a large field of view under a low 
magnifying power, about five diameters, and thus allows 
us to appreciate the general character and distribution of 


EXAMINATION OF EYE BY ARTIFICIAL LIGHT. G9 


any morbid changes better than if we begin with the direct 
method, in which the field of view is smaller and the maor- 
nifying power much greater. It has also the great advan¬ 
tage of being equally applicable in all states of refraction, 
whereas if the patient be myopic his fundus cannot be 
examined by the direct method without the aid of a suit¬ 
able concave lens, found experimentally, placed behind the 
mirror (p. 72). The inversion of the image seen by the 
indirect method is such that what appears to be upper is 
lower, and what appears to be R. is L. 

In the “direct method” the examination is made by 
the mirror alone, or with a lens behind it, but without the 
intervention of the objective lens. 

By this method the parts, unless the eye be myopic, are 
seen in their true position, Fig. 38, the upper part of the 
image corresponding to the upper part of the fundus, the 
right to the right, etc.: it is, therefore, often called the 
method of the “ erect” or “ upright” image; though, as 
will be seen below, these terms are not strictly convertible 
with “direct examination.” It is used: (1) To test the 
action of the pupils in direct fixation ; (2) to detect opaci¬ 
ties in the media, or detachment of the retina ; (3) to deter¬ 
mine the fixation power by observing the corneal reflex; 
(4) to ascertain the condition of the patient’s refraction— 
i. e.y the relation of his retina to the focus of his lens- 
system ; (5) for the minute examination of the fundus by 
the highly magnified, virtual, erect image (Fig. 39). 

1. The patient should be directed to look at the sight-hole 
of the mirror, and the light should be turned alternately 
on and off the eye; the change in shape and size of the 
pupil will then be seen as the light falls on the yellow spot. 

2. To examine the media, the patient should move his eyes 
freely in different directions while the light is thrown into 
the pupil from a distance of about twelve inches. Detach¬ 
ments of the retina may be seen, as well as opacities in the 


Fig. 38. 


70 


MEANS OF DIAGNOSIS. 



eye divergent would be focussed behind the retina as at/, and hence illuminate the fundus diffusely. The returning 
pencils (thin lines) are parallel or divergent, according as the eye is E. or EL, on leaving the eye, and appear to pro¬ 
ceed from a highly magnified erect image im\ behind the eye. It is seen that only those lamp-rays which strike close 
to the sight-hole are available ; if the hole be too large no rays will enter the pupil, and the fundus will not be illumi¬ 
nated. 







EXAMINATION OF EYE BY ARTIFICIAL LIGHT. 71 


cornea, lens, and vitreous. These latter will appear black 
against the red background of the eye. For more careful 
examination of fine opacities, a strong convex lens is placed 
behind the mirror, and the observer draws nearer to the 
patient. 

3. This method, attention to which was called by 
Priestley Smith, is practised in the following way: The 
patient is told to look at the mirror; the observer turns 
the light on one of the patient’s eyes, and notices the 
exact position of the light reflex from the surface of the 
cornea; he then quickly turns the light to the other eye, 
and compares the position of the corneal light reflex in 
the two eyes. The corneal reflex generally stands a little 
nearer the inner than the outer edge of the pupil, as the 
visual axis usually lies to the inner side of the axis of the 
cornea; if both eyes be properly directed, the position of 
the corneal reflex will be symmetrical in the two eyes. I 11 
this way imperfect fixation or strabismus will be readily 
detected. 

4. To ascertain the refraction : If, when using the mirror 
alone at a distance of 12"-18", or more, from the patient’s 
eye, we see some of the retinal vessels clearly and easily, 
the eye is either myopic or hypermetropic. If, when the 
observer’s head is moved slightly from side to side, the 
vessels seem to move in the same direction, the image seen 
is a virtual one and the eye hypermetropic. The eye is 
myopic if the vessels seem to move in the contrary direc¬ 
tion ; the image in M. is, indeed, formed and seen in the 
same way as the inverted image seen by the “indirect” 
method of examination (compare Figs. 36 and 117), but 
except in the highest degrees of M. it is too large and too 
far from the patient to be useful for detailed examination. 
In low degrees of M. this image is formed so far in front 
of the patient’s eye as to be visible only when the observer 
is distant perhaps 3 r or 4 '; while in E. and in the lower 


72 


MEANS OF DIAGNOSIS. 


degrees of H. the (erect) image will not be easily seen at 
a greater distance than 12" or 18" (Fig. 14). If, there¬ 
fore, in order to get a clear image by the direct method, 
the observer has to go either very near to, or a long way 
from, the patient, no great error of refraction can be 
present. 

The above tests only reveal qualitatively the presence of 
either M. or H., but by a modification of the method the 
quantity of any error of refraction— e. g., H., can be de¬ 
termined with great accuracy. Determination of the refrac¬ 
tion by the ophthalmoscope. In E. the erect image can be 
seen only if the observer be near to the patient, and also 
completely relax his accommodation; for when the ob¬ 
server’s head is withdrawn from the patient’s eye the field 
of view of illumination rapidly diminish, hence in E. no 
useful view can be gained by the direct method without 
going very near to the eye. 

In H., where the retina is within the focus of the lens- 
system, the erect image is seen when close to the patient’s 
eye only by an effort of accommodation in the observer, 
but it can also be seen at a distance as well as close to the 
patient. 

If now the observer, instead of increasing the convexity 
of his crystalline, place a convex lens of equivalent power 
behind his ophthalmoscope mirror, this lens will be a 
measure of the patient’s H.— i. e., it will be the lens 
which, when the patient’s accommodation is in abeyance, 
will be needed to bring parallel rays to a focus on his 
retina. If a higher lens be used, the fundus will be more 
or less blurred. 

Hence to measure H.: (1) Acc. both in patient and 
observer must be fully relaxed, usually by atropine in the 
patient and by voluntary effort in the observer; (2) the 
observer must go as close as possible to the patient; (3) he 
must then place convex lenses behind his mirror, begin- 


EXAMINATION OF EYE BY ARTIFICIAL LIGHT. 73 


ning at the weakest and increasing the strength, till the 
highest is reached which still permits the details of the 
o. d., or, better, of the y. s., to be seen with perfect clear¬ 
ness. By practice the distance between the cornete of 
patient and observer may be reduced to about 1". The 
light must be on the same side as the eye under examina¬ 
tion. The right eye must examine the right, and vice versa. 

In the same way, though with less accuracy in the high 
degrees, M. can be measured by means of concave lenses; 
the lowest lens with which a clear, erect image is obtained 
being slightly more than the measure of the M. 

It is sometimes useful to know how much lengthening or 
shortening of the eye corresponds to a given neutralizing lens. 
The following numbers, slightly altered from Knapp, are suffi¬ 
ciently near the truth. The distance between the eye of the 
observer and that of the patient is supposed to he not more 
than 1 inch. 


H. 

of 1 

D. represents shortening 

of 0.3 

mm 

u 

2 

a 

fi 

0.5 

u 

«c 

3 

.< 

cc 

1.0 

u 

(< 

5 

It 

cc 

1.5 

u 

(( 

6 

a 

cc 

2.0 

cc 

a 

9 

tc 

ic 

3.0 

a 

cc 

12 

cc 

il 

4.0 

11 

it 

18 

It 

cc 

G.O 

cc 

M. 

of 1 

D. represents leng 

thening of 0.3 

mm, 

(i 

2 

ic 

cc 

0.5 

cc 

(( 

3 

ll 

cc 

0.9 

cc 

ti 

5 

cc 

(( 

1.3 

cc 

(i 

6 

a 

cc 

1.75 “ 

u 

9 

cc 

ll 

2.6 

cc 

t . 

12 

ti 

tl 

3.5 

u 

«< 

18 

ll 

cc 

5.0 

cc 


Astigmatism (As.) may also be measured by this method, 
the refraction being estimated successively in the two chief 
meridians by means of appropriate retinal vessels. See 


74 


MEANS OF DIAGNOSIS. 


Astigmatism. Any line— e. g., a horizontally running 
vessel—is seen by means of rays which pass through the 
meridian of the cornea at a right angle to its course; 
hence if a vertical vessel be clearly seen through a -f 2D. 
lens there is H. 2 D. in the horizontal meridian, etc. 

This application of the direct method needs much prac¬ 
tice. The lenses, of which there are twenty or more, are 
so placed that they can be revolved behind the mirror 
and brought in succession opposite the sight-hole. There 
are many forms of these “refraction ophthalmoscopes,” 
varying in the details of their construction. See Appendix. 


Fig. 39. 



Ophthalmoscopic appearance of healthy disk, as seen in the erect image. 
Dark vessels, veins. Physiological pit stippled. X 15 diameters. (After 
Jaeger.) 

5. The erect image is very valuable, on account of the 
high magnifying power, about 20 diameters in the E. eye, 
for the examination of the finer details of the fundus. The 
disk looks less sharply defined, because more magnified, 
than when seen by the indirect method ; both the disk and 
the retina often show a faint radiating striation, the nerve- 
fibres; the lamina eribrosa is often more brilliantly white; 
and the pigment epithelium of the choroid can be recog¬ 
nized as a fine, uniform dark stippling. 

If the refraction be E. or H. no lens is needed behind 











































EXAMINATION OF EYE BY ARTIFICIAL LIGHT. 


the mirror; if M., a concave lens must be placed behind 
the mirror, of sufficient strength to give a good, clear, 
erect image. The observer must come as near as possible 
to the patient. 

By reference to Fig. 38 it will be seen that only those 
rays are useful which strike near the centre of the mirror, 
none others entering the patient’s pupil; hence, if the 
aperture in the mirror be too large the fundus will not 
be well lighted. It should not be larger than 3 mm. nor 
smaller than 2 mm. 


The Shadow Test (Retinoscopy, Skiascopy). 

By this method the refraction is determined by noticing 
the direction of movement of the light thrown on to the 


Fig. 40. 



Vertical section of healthy optic disk, etc. X about 15. R. Retina, outer 
layers shaded vertically, nerve-fibre layer shaded longitudinally. Ch. Cho¬ 
roid. Scl. Sclerotic. L. Cr. Lamina cribrosa. S. V. Subvaginal space be¬ 
tween outer and inner sheath of optic nerve. The central vein and one of 
the divisions of the central artery are seen in the nerve and disk. 


retina by the mirror, when the latter is rotated. The 
degree of error of refraction is measured by the lens, 
which, placed close to the patient’s eye in a case of 























































76 


MEANS OF DIAGNOSIS. 


ametropia, renders the movement and other characters 
of the illumination the same as in emmetropia. 

The test is most accurate when used at a great distance 
from the patient; in practice a distance of about 1 m. 
(100-120 cm., or 3'-4') is chosen. The observer, seated 
in front of his patient, throws the light from an ophthal¬ 
moscope mirror into the patient’s pupil. He will then 
see the area of the pupil illuminated, and on slightly 
rotating the mirror will notice a movement in this lighted 
area, which movement will have a direction either the 
same as, or opposite to, that in which the mirror is turned, 
“with” or “against” the mirror. The lighted area is 
bordered by a dark shadow, and it is to the edge of this 
shadow that attention must be directed. This edge is par¬ 
allel to the axis on which the mirror is turned, but moves 
in, and shows the refraction of, the meridian at right angles 
to it— e. g., the shadow whose edge passes vertically across 
the pupil moves across the horizontal meridian, the refrac¬ 
tion of which it indicates, and vice versa. Itetinoscopy may 
be practised with a concave or a plane mirror. With the 
former the shadow moves “ against ” the mirror in E., H., 
and low M., and “ with ” the mirror in M. of more than 1 D. 
With the latter these movements are exactly reversed. 
The light should be thrown as nearly as possible in the 
direction of the visual axis, and the lamp be placed imme¬ 
diately over the patient’s head rather than to one side. 

1. With a concave mirror, of about 22 cm. focus, Fig. 
41. In Fig. 41, 1, the mirror, m, forms an inverted image, 
i, of the light, l, at its principal focus, and i becomes the 
source of light for the eye, e. A second image of i, again 
inverted, is formed at T on the retina of e. If the far 
point of e be at i this retinal image, T, will be clear and 
distinct, but in every other case it will be more or less 
out of focus and indistinct. On rotating m to m', i 
will move to r and i to i'\ and these movements (of i 


EXAMINATION OF EYE BY ARTIFICIAL LIGHT. 77 


Fig. 41. 



Retinoscopy (with concave mirror). 




78 


MEANS OF DIAGNOSIS. 


and i') will occur, no matter what the refraction of e 
may be. 

The observer placed behind m sees an image of i' formed 
in the same way as the image of the fundus seen by the 
direct method, and therefore either inverted and real, or 
erect and virtual, according as the refraction of the eye 
is M. or H. (p. 72). If the observer’s eye be accurately 
adapted for this image of T, he will indeed see not only 
the light and shadow, but the retinal vessels; he neglects 
these, however, in attending to the movements of the 
shadow. 

In the following description, l, t, and i 2 are disregarded. 
T or i' 2 being considered as the source of light. 

If e be myopic , Fig. 41, 2, the image of T is real and 
inverted and formed at i", the far point of e (compare 
Fig. 117). On rotating the mirror, as in Fig. 41, 1, 7 
will move to T 2 , and i" will move to r /2 — i. e., the image 
seen by the observer moves in the same direction as (o) 
“ with ”) the mirror. 

If e be hypermetropic , Fig. 41, 3, or emmetropic, ray# 
reflected from its retina leave the eye divergent or par¬ 
allel, and are not brought to a focus after emerging; the 
observer therefore sees a virtual image erect at i", the vir¬ 
tual focus of i', compare Fig. 13, and sees its movements 
actually as they occur- -i. e., in the same direction as the 
movements of the real image T or i' 2 , and therefore 
“against” the movements of the mirror. Hence in H. 
and Em. the shadow moves against the mirror. 

The above statement for myopia is true only if the 
observer be beyond the far point of the observed eye. 
See Myopia. In M. of 1 D. the rays returning from the 
patient’s eye are focussed at a distance of 1 m., and if the 
observer intercept these rays before they meet (Fig. 41, 4) 
he will refer them toward i" and i" 2 , and obtain an erect, 
virtual but unfocussed image of i'. the movements of which 


EXAMINATION OF EYE BY ARTIFICIAL LIGHT. 79 


will be the same as those in H. or E., Fig. 41, 3— i. e., 
against the mirror. Hence, at a distance of about 1 m., 
movement “ against ” the mirror may indicate M. of about 
1 D., or E. or H. The lowest M. which can give the char¬ 
acteristic movement at this distance is slightly more than 
1 D., say 1.25 D. 

2. With a plane mirror, Fig. 42. Here the source of 
light for the observed eye is an erect and virtual image of 
the flame formed at the same distance behind the mirror 
as the lamp is in front of it. In Fig. 42, 1, this image is 
at l, the virtual focus of l. A second and inverted image 
of l is formed on the retina of e at 1 . The movements of 
these images, on rotation of the mirror, are the reverse of 
those of the image 1 (and its retinal image 1 '), Fig. 41, 1, 
obtained when the concave mirror is used. When the 
mirror m is rotated to m', l will move in the opposite 
direction to l', but its retinal image 1 will move to T— i. e ., 
in the same direction as, or with the mirror. These move¬ 
ments of l and 1 occur in every eye, whatever its refrac¬ 
tion. In E. and H., however, the movement of the retinal 
imaore is seen as it occurs, and therefore with the mirror; 
but in M., Fig. 42, 2, the observer sees an inverted image of 
1 formed at the far point of e, and its movements are exactly 
the reverse of those of the retinal image. Therefore, when 
on rotating m to m', i moves to i 2 the image T seen by the 
observer moves to i' 2 — i. e., against the mirror. If the plane 
mirror be used at a distance of rather more than 1 m. (3'-4') 
from the patient, a movement of the shadow with the 
mirror will occur in M. of 1 D. or less, for the reasons given 
previously, Fig. 41, 4; but if the observer be about 2 m. 
(say 7') away the characteristic movement against the mir¬ 
ror will be obtained unless the M. be less than 0.5 D.; 
since the far point of an eye with M. 0.5 D., and there¬ 
fore the image seen, is at 2 m. As a plane mirror gives 
at a long distance a better illumination than a concave one, 


Fig. 42. 


80 


MEANS OF DIAGNOSIS . 



Retinoscopy (with plane mirror ). 





EX A MIN A TION OF EYE BY ARTIFICIAL LIGHT, gj 


it can, if necessary, be used at a greater distance from the 
patient, and by this means low degrees of ametropia be very 
accurately measured. Generally, however, the distance 
given (3'-4') will be found most convenient. 

In employing retinoscopy the patient is armed with a 
trial frame into which lenses are successively put until 
one is reached which just reverses the movement of the 
shadow. This lens indicates nearly, but not quite, the 
refraction of the eye under observation. In H. we must 
subtract (about) 1 D. from the lowest -f- lens which re¬ 
verses the shadow, because we know that this movement 
would not occur till a myopia of at least 1 D. had been 
produced. In M., for the same reason, 1 D. must be added 
to the lowest — lens which reverses the shadow. 

Astigmatism is easily detected, and Its amount measured 
by observing, on rotating the mirror, first from side to side, 
then from above downward, whether the shadow has the 
same movement and characters in each direction; or by 
noting that when the shadow in one meridian is “corrected ” 
by a lens, the meridian at right angles to it still shows de¬ 
cided ametropia. The lens is then found which corrects 
the latter meridian, and the As. equals the difference 
between the two lenses. 

Apart from the direction in which the image (and shadow) 
moves, something maybe learned from variations in (1) its 
brightness ; (2) its rate of movement; (3) the form, straight 
or crescentic, of its border. The image is brightest, its 
movement quickest and most extensive, in very low M. 
and in Em. The higher the ametropia, whether M. or 
H., the duller is the illumination, the slower and less 
extensive its movement, and the more crescentic and ill- 
defined its shadow border. The brightness of the image 
depends on how clearly i, Fig. 41, 1, is focussed on the 
retina ; the more accurately T is an image of i, the brighter 
and larger will i", Fig. 41, 2 or 3, be; and as the flame is 

6 


82 


MEANS OF 1)1 A GNOSIS. 


rectangular, the borders of the image will be nearly straight. 
These conditions occur when the eye is exactly adapted 
for the distance of i— l. e., in M. of 1 D. or less. If the 
M. be higher than 1 D.,i will be out of focus, and there¬ 
fore be spread over a larger retinal area, and being formed 
by the same number of rays as before, it will be less bright. 
The image i", Fig. 41, 2, will be correspondingly diffused 
and dull, and being formed nearer to the patient’s eye, as 
for example at x, it will move only from x to x' in the 
same time as i" takes in moving to i" 2 , and hence its move¬ 
ment is slower and less extensive. The same is true in H., 
Fig, 41, 3, because the higher the H., the more diffused is 
i' and the nearer is i" to the patient’s eye. In both cases, 
high M. and high H., the border of the shadow is cres¬ 
centic because the diffused image forms a nearly round 
area on the retina. 

Some American retinoscopists are accustomed to perform 
the shadow test with the light close to the eye of the ex¬ 
aminer, while the patient is seated precisely 1 m. distant. 
A small plane mirror is employed, and the light is obtained 
through an aperture in a cover chimney, which should not 
be more than 1 cm. in diameter. It is claimed for this 
method that a much more brilliant and smaller reflection 
is obtained than when the light is placed behind the patient, 
and that more accurate results are rendered possible. 

Retinoscopy is a valuable means of objectively determin¬ 
ing the quantity of any error of refraction, and as it is 
more easily learned, and on the whole more accurate in its 
results, than estimation by the direct method, it has, in the 
hands of many, almost displaced the latter method during 
the last four or five years as a preliminary to testing the 
patient with trial lenses. For the quick discovery of very 
slight astigmatism, and of the direction of the chief meri¬ 
dians in astigmatism of all degrees, retinoscopy probably 
excels all other methods. 


EXAMINATION OF EYE BY ARTIFICIAL LIGHT. 83 


Retinoscopy, however, carries with it none of the col¬ 
lateral advantages afforded by a thorough training in the 
more difficult “direct method for in retinoscopy we see 
nothing and think nothing of the condition of the fundus 
of the eye. Accurate retinoscopy is not quicker than 
measurement by this direct method; indeed, with a good 
instrument the latter method certainly has the advantage 
in rapidity. 






PART II. 

CLINICAL DIVISION. 


CHAPTER IV. 

DISEASES OF THE EYELIDS. 

The border of the lid, which contains the Meibomian 
glands, the follicles of the eyelashes, and certain modified 
sweat-glands and sebaceous glands, is often the seat of 
troublesome disease. Being half skin and half mucous 
membrane, it is moist and more susceptible than the skin 
itself to irritation by external causes; being a free border, 
its circulation is terminal, and therefore especially liable 
to stagnation. Its numerous and deeply-reaching glandu¬ 
lar structures, therefore, furnish an apt seat for chronic 
inflammatory changes. 

Blepharitis (ophthalmia tarsi, tinea tarsi, sycosis tarsi) 
includes all cases in which the border of the eyelid is the 
seat of subacute or chronic inflammation. There are sev¬ 
eral types. The skin is not much altered, but chronic thick¬ 
ening of the conjunctiva near the border of the lid is gen¬ 
erally observed. The disease may affect both lids or only 
one, and the whole length or only a part. 

In the commonest and worst form the glands and eye¬ 
lash-follicles are the principal seats of the disease. The 
symptoms are, firm thickening and dusky congestion of 
the border region, with exudation of sticky secretion from 

(85) 



86 


CLINICAL DIVISION. 


its edge, gluing the lashes together into little pencils. Very 
mild cases present merely overgrowth of lashes and excess 
of Meibomian secretion. But generally the disease pro¬ 
gresses ; little excoriations, and ulcers covered by scab, 
form along the free border, and often minute pustules 
appear; the thickening and vascularity increase; the 
lashes are loosened, and free bleeding occurs if they are 
pulled out. After months or years of varying activity 
some or all of the hair-follicles become altered in size and 
direction, or quite obliterated, and the lashes stunted, mis¬ 
placed, or entirely lost. As the thickening gradually dis¬ 
appears, little lines, or thin seams, of scar form just within 
the edge of the lid, and often cause slight eversion. The 
resulting exposure of the marginal conjunctiva, added to 
the scantiness of the cilia, causes the disagreeably raw and 
bald appearance termed lippitudo; and epiphora, from 
eversion, tumefaction, or narrowing of the puncta, often 
results. Often, however, the disease leads to nothing 
worse than the permanent loss of a certain number of the 
lashes. 

In another type the changes are quite superficial—mar¬ 
ginal eczema ; the patient is liable, perhaps through life, to 
soreness and redness of the borders of the lids, and little 
crusts, scales, or pustules form at the roots of the lashes, 
the growth of the lashes not being much interfered with. 
In such people the eyes look weak or tender; the condi¬ 
tion is made worse by exposure to heat, dust, and wind, 
and by long spells of work. See Chronic Lacrhymal Con¬ 
junctivitis, p. 121. 

Ophthalmia tarsi generally begins in childhood, and an 
. attack of measles is a common exciting cause. It seldom 
becomes severe or persistent except from neglect of clean¬ 
liness in a child with sluggish circulation ; the patients are 
generally anaemic, often scrofulous, and the condition is 
then often the result of a previous more acute ophthalmia. 


DISEASES OF TIIE EYELIDS. 


87 


In adults severe sycosis of the eyelids may accompany 
sycosis of the beard, but, as a rule, no tendency to such 
disease of the skin is observed. 

Treatment.— When the inflammatory symptoms are 
severe nothing has such a marked effect as pulling out all 
the lashes. Cases of a few weeks’ standing may be cured 
and recurrences in older cases very much relieved by one or 
two such epilations, together with local remedies. Local 
applications are always needed (1) for the removal of the 
scabs ; (2) to subdue the inflammatory symptoms. A warm 
alkaline and tar lotion, with which the lids are to be care¬ 
fully soaked for a quarter of an hour night and morning, 
followed by a weak mercurial ointment applied along the 
edges of the lids after each bathing, is an efficient plan if 
the mother will take pains. In bad cases painting, or pen¬ 
cilling, the border of the lid with nitrate of silver, either in 
strong solution, or the diluted stick, or the use of weak 
copper drops, is very useful in addition to the ointment. 
In old cases with much epiphora the canaliculus is to be 
slit up. The patients generally need a long course of iron. 
(F. 1, 2, 3, 6, 18, 19, 20, 28, 29.) 

A stye is the result of suppurative inflammation of the 
connective tissue, or of one of the glands, in the margin 
of the lid. Owing to the close texture of the tarsus and 
the vascularity of the parts, the pain and swelling are 
often severe, and even alarming to the patient. The 
matter generally points around an eyelash ; but if seated 
in a Meibomian gland, it may point either to the border 
of the lid or to the conjunctiva, rarely to the skin. 

Styes almost always show some derangement of health, 
especially of the stomach or reproductive organs. Over¬ 
use of the eyes, especially if ametropic, is the exciting 
cause in some cases; exposure to cold wind in others. 
Styes are very apt to recur, singly or in crops, for several 
weeks or months. 


88 


CLINICAL DIVISION. 


Treatment. —A stye may sometimes be cut short, if 
seen quite early, by the vigorous use of an antiphlogistic 
lotion; but an incision followed by hot fomentations or 
a poultice is usually more efficacious; the puncture must 
be made parallel to the free border, and extend rather 
deeply; a Beer’s knife or broad needle, Figs. 176 and 
161, may be used. The health always needs attending 
to, and a purgative iron mixture often suits better than 
anything else. 

Some persons are subject to very small pustules or styes, 
much more superficial than the above, and less closely 
associated with derangement of health. 

A Meibomian gland is often the scene of chronic over¬ 
growth, a little tumor in the substance of the lid being the 

Fig. 43. 



Chalazion. (Dalrymple.) 


result—Meibomian cyst, chalazion. In a few weeks or 
months the growth becomes as large as a pea, forming a 
firm, hemispherical, painless swelling, over which the 
skin is freely movable. A dusky spot where the tarsal 
tissues are thinned marks the conjunctival aspect, and 
when spontaneous rupture has occurred, a flattened mass 




DISEASES OE THE EYELIDS. 


89 


of granulation is found there. The deeper part of the 
gland is the common seat of disease; if, as sometimes 
happens, the part near the edge of the lid is affected, the 
tumor usually remains very small. Occasionally the 
growth pushes forward, and adhesion to the skin occurs; 
even then it is easily distinguished from a sebaceous cyst 
by the firmness of its deep attachment. During its course 
the cyst may inflame and even suppurate, and in the latter 
case it forms one variety of “ stye.” The same tumor may 
inflame several times, and finally suppurate and shrink. 
Like styes, these tumors are apt to continue forming one 
after another. They are much commoner in young adults 
than earlier or later in life, but they are now and then seen 
in infants. Patients as often apply for the disfigurement 
as for any discomfort which these little growths occasion. 

Treatment.— The cyst is to be removed from the inner 
surface of the lid ; but if it points forward, the incision 
may be in the skin. The tumor generally consists of a 
soft, pinkish, gelatinous mass, or of a gruelly or puriform 
fluid, without a cyst wall. Sometimes the contents are 
very firm and adherent. See Operations. 

Small yellow dots are sometimes seen on the inner sur¬ 
face of the lids, due to little cheesy collections in the Meibo¬ 
mian glands, and causing irritation by their hardness. 
They should be picked out with the point of a knife. 

Warty formations are not very common on the border 
of the lid, and are of little consequence except in elderly 
people, in whom they should be looked upon with suspi¬ 
cion as possible starting-points of rodent cancer. A small, 
fleshy, yellowish-red, flattened growth is sometimes met 
with just upon the tarsal border, and apparently seated at 
the mouth of a Meibomian gland. It causes some irrita¬ 
tion, and should be pared off. Small pellucid cysts are also 
not uncommon on the lid border. Cutaneous horns are 
occasionally seen on the skin of the eyelids. 


90 


CL I SIC A L DIVISION. 


Molluscum contagiosum is partly an ophthalmic disease, 
because so often seated upon the eyelids. One or more 
little rounded prominences, showing a small dimpled ori¬ 
fice at the top, plugged by dry, sebaceous matter, are seen 
in the skin, varying from the size of a mustard-seed to a 
cherry, but usually not larger than a sweat-pea; at first 
they are hemispherical, but afterward become constricted 
at the base. The skin is tightly stretched, thinned, and 
adherent. The larger specimens sometimes inflame, and 
their true nature may then, without due care, be mis¬ 
taken. Each molluscum must be removed, the white, 
lobulated, gland-like mass which forms the growth being 
squeezed out through the incision made by a knife or scis¬ 
sors. 

Xanthelasma palpebrarum appears as one or more yellow 
patches like pieces of wash-leather in the skin, varying 
from mere dots to the size of a kidney bean, quite soft in 
texture, and very little raised. The disease is commonest 
near the inner canthus, and unless symmetrical is usually 
on the left side. It occurs chiefly in elderly persons who 
have previously been subject to become very dark around 
the eyes when out of health. The patches are due to in¬ 
filtration of the deeper parts of the skin by groups of cells 
loaded with yellow fat. The frequency of xanthelasma in 
the eyelids is, perhaps, related to the normal presence of 
certain peculiar granular cells, some of which contain pig¬ 
ment, in the skin of these parts. 

The pediculus pubis (crab-louse) in very rare cases will 
reach the eyelashes and flourish there. The lice cling close 
to the border of the lid, and look like dirty scabs; the eggs 
are darker, and may also be mistaken for bits of dirt. The 
absence of inflammation and the rather peculiar appear¬ 
ances will lead, in doubtful cases, to the use of a magnify¬ 
ing glass, by which the question will be at once settled. 

Ulcers on the eyelids may be malignant, tubercular, 


DISEASES OF TIIE EYELIDS. 


91 


lupous, or syphilitic; and in the last case the sore may 
be either a chancre or a tertiary nicer. 

j 

Rodent cancer (rodent ulcer, flat epithelial cancer) is by 
far the commonest form of carcinoma affecting the eye¬ 
lids ; cases of eyelid cancer occasionally present both the 
clinical and pathological characters of ordinary epithe¬ 
lioma. The peculiarities of rodent cancer are that it is 
of very slow growth, that ulceration almost keeps pace 
with the new growth, and that it does not cause infection 
of lymphatics. It seldom begins before, generally not 
until considerably after, middle life, and its course often 
extends over many years. Beginning as a “pimple” or 
“ wart,” it slowly spreads, but years may pass before the 
ulcer is as large as a sixpence. When first seen we gener¬ 
ally find a shallow ulcer, covered by a thin scab, most 
often involving the skin at the inner end of the lower lid. 
its edge is raised, sinuous, nodular, and very hard, but 
neither inflamed nor tender. Slowly extending both in 
area and depth, it attacks all tissues alike, finally destroy¬ 
ing the eyeball and opening into the nose. In a very few 
chronic cases the disease remains quite superficial, and 
cicatrization may occur at some parts of the ulcerated 
surface. Now and then a considerable nodule of growth 
forms in the skin before ulceration begins. 

The diagnosis is generally easy. A long-standing ulcer 
of the eyelids in an adult is nearly certain to be rodent 
cancer. Tertiary syphilitic ulcers are much less chronic, 
more inflamed and punched out, and devoid of the very 
peculiar, hard edge of rodent ulcer; moreover they are 
very rare. Lupus seldom occurs so late in life as rodent 
cancer, presents more inflammation and much less hard¬ 
ness, and is often accompanied by lupus elsewhere on the 
cutaneous or mucous surfaces. Lupus is seldom difficult 
to distinguish on the eyelids from tertiary syphilis, the 
latter being more acute, more dusky, and showing more 


92 


CLINICAL DIVISION. 


loss of substance, with none of the little, ill-defined, soft 
tubercles seen in lupus. 

When a chancre occurs on the eyelid 1 the induration and 
swelling are usually very marked, the surface abraded and 
moist, but not much ulcerated; the glands in front of the 
ear and behind the jaw become much enlarged. 

Several cases are on record in which a hard chancre 
formed on the palpebral conjunctiva, so far from the 
border of the lid as to be quite concealed. In such cases 
the swelling bears considerable resemblance to a large 
Meibomian cyst; there are enlarged glands and well- 
marked constitutional symptoms. 

Treatment of Rodent Cancer. Early removal is 
of great importance, and probably the more so in pro¬ 
portion to the youth of the patient. Chloride of zinc 
paste or the actual cautery is necessary in addition to 
the knife in bad cases; scraping may also be employed. 
The disease is very apt to return locally. Even in very 
advanced cases, where complete removal is impossible, 
the patient may be made much more comfortable, and 
life probably prolonged, by vigorous and repeated treat¬ 
ment. 

Tubercle of the Conjunctiva is generally primary; it 
begins in the upper lid in the tarsal conjunctiva, or in the 
retrotarsal fold; as a rule, the upper lid is swollen, and 
when everted presents either a punched-out ulcer with a 
gray base, or a mass of small gray miliary tubercles. The 
pre-auricular gland is very frequently enlarged, and may 
suppurate. If left alone the disease may spread to the 
eyeball, or invade the substance of the lid, and may lead 
to secondary infection of other parts of the body. The 
diseased parts should be excised, or thoroughly scraped 
and cauterized, and the operation should be repeated as 
long as any trace of the disease remains. 

n j 

1 An interesting monograph on this subject was read by Dr. De Beck at the 
American Ophth. Soc., July, 1SS6. 


DISEASES OF THE EYELIDS. 


93 


Congenital ptosis is a not very rare affection. It may be 
double or unilateral, is present from birth, and its causation 
is unknown. I believe it is never complete. It sometimes 
seems to diminish in the first few years of life, but probably 
never disappears. Although the lid droops, the skin is often 
scanty, the lid being tight and deficient in the natural 
folds. Operations have been devised for producing deep 
cicatricial bands, by means of subcutaneous sutures passed 
from the brow to the tarsus (Bowman, Pagenstecher, 
Wecker). Panas has devised a new operation more re¬ 
cently. These rather tedious procedures avoid the risk of 
further shortening of the lid which attends the simpler 
operation of removing an elliptical fold of skin. I have 
obtained considerable improvement from Pagenstecher’s 
operation. 

Epicanthus is a rare condition, in which a fold of skin 
stretches across from the inner end of the brow to the side 
of the nose, hiding the inner canthus. If it does not dis¬ 
appear as the child’s nose develops, an operation—removal 
of a piece of skin from the bridge of the nose, sometimes 
combined Avith canthoplasty—is indicated. 

Congenital trichiasis. This condition is not very uncom¬ 
mon in children; the lashes of the lower lid, instead of 
having their normal direction, are turned upward and 
backward, and come into contact Avith the globe, giving 
rise to irritation of the conjunctiva and cornea. To restore 
the lashes to their proper direction, an elliptical piece of 
skin should be removed from the loAver lid. 


CHAPTER V. 


DISEASES OF THE LACHRYMAL APPARATUS . 1 

These may be divided into the affections of the secreting 
parts—the lachrymal gland and its ducts; and those of the 
drainage apparatus—the puncta, canaliculi, lachrymal sac, 
and nasal duct. In the great majority of cases the fault 
lies entirely in the drainage system. 

The flow of tears over the edge of the lid, “ watery eye,” 
is called epiphora or stillicidium lacrymarum. No useful 
purpose is served by keeping the two names, and only the 
former will be here used. Lachrymation indicates the in¬ 
creased flow which often accompanies inflammation of the 
eyeball. 

Diseases of the Secretory Apparatus. 

Dacryoadenitis.— Inflammation of the lachrymal gland 
is of rare occurrence, either in the acute or chronic form. 
It is indicated by swelling and oedema of the upper lid, 
and pain and tenderness on pressure of the gland and the 
adjacent supraorbital margin. The disease may assume a 
purulent form, when an abscess may open either upon the 
conjunctiva or through the skin. 

Rheumatism, cold, syphilis, septicaemia, and mumps have 
all been ascribed as the cause in various cases, while the 
spread of inflammation from the conjunctiva and cornea 
has been noted in a number of instances. 

Treatment. —Hot applications and poultices in the 
early stages, followed by free incision under the supra¬ 
orbital region as soon as pus has formed. In the chronic 
( 94 ) 


DISEASES OF TIIE LACHRYMAL APPARATUS. 95 


variety the local application of absorptive ointments, such 
as the mercurial and compound iodine, should be employed, 
while potassium iodide, mercury, and the salicylates should 
be administered internally. In acute cases an active calo¬ 
mel purge should be prescribed, followed by large doses 
of quinine. 

Neoplasms, such as sarcoma and adenoma, and hyper¬ 
trophy of the gland, are of rare occurrence. The latter 
is at times of congenital origin, but is usually an affection 
of later years. The gland may attain a large size, and 
cause serious damage to the eyeball by compression. 

Diseases of the Excretory Apparatus. 

The drainage system may be at fault in any part from 
the puncta to the lower end of the nasal duct. 

The slightest change in the position of the lower punc- 
tum causes epiphora. In health the punctum is directed 
backward against the eye; if it look upward or forward 
the tears do not all reach it, and some will then flow over 
the lid. Thus in paralysis of the facial nerve the patient 
sometimes comes to us for epiphora before he notices the 
other symptoms; the watering is caused partly by loss of 
the compressing and sucking action of the punctum that is 
effected in winking, by those fibres of the orbicularis which 
lie in relation with the lachrymal sac, partly by a slight 
falling of the lid away from the eye and a consequent dis¬ 
placement of the punctum. The various chronic diseases 
of the border of the lids (ophthalmia tarsi), and also gran¬ 
ular disease of the conjunctiva (granular lids), are common 
sources of (1) tumefaction, with narrowing, of the puncta 
and canaliculi; (2) cicatricial stricture of the same parts; 
in both cases the puncta are displaced as well as con¬ 
stricted. Narrowing even to complete obliteration of the 
puncta is sometimes seen as the result of former inflam¬ 
mation, of which all traces have long since passed away. 


96 


CLISICA L DIVISION. 


Wounds bv which the canaliculi are cut across cause their 

m 

obliteration, and epiphora is the result. 

In all the above cases the epiphora is accompanied by a 
visible change in the size or position of the punetum, none 
of the signs of inflammation in the lachrymal sac or stric¬ 
ture in the nasal duct being present; and simple division 
of the canaliculus will cure, or much relieve, the watering. 
See Operations. This is, however, seldom necessary in the 
epiphora of facial paralysis. 

The canaliculus is occasionally plugged by the growth 
in it of a mycelial fungus, which, mingled with pus-cells 
and mucus, forms a yellowish or greenish, putty-like con¬ 
cretion. These masess sometimes calcifv, and are then 
called daeryoliths. 1 2 

Epiphora not explained by the above causes is usually 
due to obstruction in the nasal duct, and is accompanied 

bv distention and disease of the laehrvmal sac from the 

« • 

same cause. Primary disease of the lachrymal sac is rare. 

Obstruction of the nasal duct is usually caused by chronic 
thickening of the mucous and submucous tissues lining the 
canal. Dense, hard thickening causes a stricture, often 
very tight and unyielding; but obstruction is often present 
though the canal be of full size or perhaps even dilated,* 
excess of mucus being apparently the chief cause. Disease 
of the duct occurs at all ages, and is more common in 
females than males. 3 In some cases the change evidentlv 
forms a part of a chronic disease of the naso-pharyngeal 
mucous membrane, but in many no cause can be assigned. 
Sometimes stricture is the result of periostitis or of necrosis, 
and of these conditions syphilis, either acquired or inher- 

1 The same term is applied to concretions, stUl more rare, in the ducts of 
the lachrymal gland. 

2 There can be little doubt that the healthy nasal duct varies much in size 
in different persons (Xoyes). 

s In a group of 113 consecutive cases I find S9 females and 24 males. 


DISEASES OF THE LACHRYMAL APPARATUS. 97 


ited, scarlet fever, and smallpox are the more common 
causes. Injuries to, and growths in, the nose, or invading 
it, account for a few cases. 

A stricture may be seated at any part of the duct; but 
the upper end, where there is often a natural narrowing, is 
the commonest spot. 

Obstruction of the nasal duct, by preventing the escape 
of tears, leads to distention of the lachrymal sac, to chronic 
thickening of its lining membrane, and increased secretion 
of mucus. The mucus may be clear or turbid. At length 
a point is reached at which the distention can be seen as a 
little swelling under the skin at the inner canthus, mucocele 
or chronic dacryocystitis. This swelling can generally be 
dispersed by pressure with the finger, the mucus and tears 
either regurgitating through the canaliculi or being forced 
through the duct into the nose. In cases of old standing 
the sac is often much thickened, and may contain polypi, 
and the swelling cannot then be entirely dispersed by pres¬ 
sure. 

A mucocele is always very apt to inflame and suppurate, 
the result being a lachrymal abscess. Most cases of lachry¬ 
mal abscess, indeed, have been preceded by mucocele. Its 
formation gives rise to great pain, and to tense, brawny, 
dusky swelling, which, extending for a considerable dis¬ 
tance around the sac, is sometimes mistaken for erysipelas. 
The matter always points a little below the tendo palpebra¬ 
rum ; the pus often burrows in front of the sac, forming 
little pouches in the cellular tissue, and if allowed to open 
spontaneously, a fistula, very troublesome to cure, is likely 
to follow. If seen early, before there is decided pointing, 
it is best to open the abscess by slitting the lower canal¬ 
iculus freely into the sac, and passing a knife down the 
nasal duct; anaesthesia is usually necessary. If interfer¬ 
ence be delayed, the skin over the sac soon becomes thinned, 
and the abscess is then best opened through the skin by 

7 


98 


CLINICAL DIVISION. 


a free puncture inclined downward and a little outward; 
no anaesthetic is necessary, and the resulting scar is insig¬ 
nificant. When the thickening has subsided, under the 
use of warm lead lotion dressing, the stricture of the duct 
is to be treated; but the mucocele will form again, and 
another abscess may occur at any time unless a free pass¬ 
age can be restored down the nasal duct. 

Obstinate chronic conjunctivitis is often set up by unre¬ 
lieved lachrymal obstruction (p. 121). It has long been 
known that severe suppurative inflammation is very likely 
to occur after any operation performed on the cornea when 
there is pus in the lachrymal sac. See Cataract. These 
evidences of local irritation and infection are now known 
to depend upon septic organisms, which, owing to the 
obstruction, collect in the lachrymal sac. 

Treatment of Mucocele and Lachrymal Stric¬ 
ture. The object aimed at is the permanent dilatation 
of the stricture; but, whether this can be gained or not, 
a free opening from the canaliculus into the sac should be 
maintained, so that the secretions may be often and easily 
squeezed out. 

This may be either palliative or curative. The former 
consists in repeatedly pressing the contents of the lachry¬ 
mal sac into the nose by the finger, and by the employ¬ 
ment of antiseptic and astringent eye washes, or by throw¬ 
ing a stream of boric acid solution into the sac by means 
of an Anel syringe. Attention must be directed toward 
the nasal mucous membrane, and any local irritation exist¬ 
ing about the nasal opening of the duct must be controlled 
with local applications. 

The curative plan of treatment resolves itself into some 
form of surgical procedure. These measures have been 
conveniently classed by Theobald under four heads: 1. 
Those which aim to restore the natural passages. 2. Those 
which have for their object the formation of a new passage 


DISEASES OF THE LACHRYMAL APPARATUS. 99 


into the nose for the tears. 3. Those which aim at the 
obliteration of the natural passages—the lachrymal sac and 
duct. 4. The removal of the lachrymal gland for the pur¬ 
pose of arresting the secretion of tears. 

Dilatation by probing, Chapter XXII., is the ordinary 
and best treatment for all strictures, whether there be 
mucocele or not, the rule being to use the largest probe 
that will pass readily. The probing is repeated every few 
days or less often, according to the duration of its effect, 
and often needs to be continued for weeks or months. The 
patient may sometimes learn to use the probe himself. 
When the stricture is tough and tight, it is best at once 
to divide it by thrusting a strong-backed, narrow knife 
down the duct, and afterward to use probes. In cases 
where the stricture is quite soft, and the obstruction due 
rather to general thickening of the mucous membrane and 
over-secretion of mucus, than to dense fibrous thickening, 
frequent washing out of the duct with water, or weak 
astringents, by means of a lachrymal syringe, is quite as 
beneficial as, and less painful than, probing. The diligent 
use of astringent lotions to the conjunctiva is also useful, 
particularly in soft strictures, some of the lotion reaching 
the sac and duct. In cases of long standing, where other 
treatment has failed and the sac is much thickened, or 
when it is necessary to perform an operation like extrac¬ 
tion of cataract, excision of the lachrymal sac, or its com¬ 
plete obliteration by the actual cautery, should be resorted 
to; extirpation of the lachrymal gland is also occasionally 
practised. For refractory children, and for patients who 
cannot be seen often, a style of silver or lead, passed in 
exactly the same way as a probe, but worn constantly for 
many weeks, is very useful; but it may slip into the sac 
out of reach unless furnished with a bend or head so large 
as to be somewhat unsightly. As a rule, probing should 
not be begun until the inflammatory thickening and ten- 


UcfC/ 


> ‘ > 


100 


CLINICAL DIVISION. 


derness following a lachrymal abscess have subsided. If 
the probe be used too often, or with much violence, or if 
false passages be made, the case may easily be made worse 
instead of better. It must be confessed, indeed, that in 
many lachrymal cases, whether the stricture be soft or 
firm, treatment, however skilful, gives only partial relief 
to the epiphora. 

Suppuration of the lachrymal sac, on one or both sides, 
sometimes takes place in newborn infants without apparent 
cause; if there be much redness, the abscess should be 
opened, but the suppuration is sometimes chronic, and 
will cease under the use of astringent lotions. The cases 
of epiphora with contracted punctum, which are sometimes 
met with in older children, may perhaps be the conse¬ 
quences of this infantile suppuration. 

Cases in which the sac or duct is obliterated by injury 
can seldom be relieved. 


i 

i 

> t. 


< ’ \ 
c 



* 


CHAPTER VI. 


DISEASES OF TIIE CONJUNCTIVA. 

The conjunctiva, like the urethra, is subject to purulent 
inflammation, and, like the respiratory mucous membrane, 
is liable to the muco-purulent and to the membranous or 
diphtheritic forms of disease. All cases in which there is 
yellow discharge are in greater or less degree contagious. 
The congestion, which forms a part of conjunctivitis, is 
much influenced by age; the younger the patient the less 
is the congestion in proportion to the discharge—a fact to 
be borne in mind in examining patients at both ends of 
the scale. 

Purulent ophthalmia (0. neonatorum, Gonorrhoeal O., 
Blennorrhoea of the conjunctiva) is generally due to con¬ 
tagion from the same disease, or from an acute or chronic 
discharge from the urethra or vagina, which may or may 
not be gonorrhoeal. It is commonest in newborn infants 
whose eyes have been inoculated from the mother during 
birth ; next in adults with gonorrhoea; it is also seen some¬ 
times in young girls who have non-venereal discharge from 
the genitals. 

The active cause of this form of conjunctivitis is a micro¬ 
organism, the gonococcus, first discovered by ISTeisser in 
1879. These are found in the pus-cells of the conjunctival 
discharge, and also in the superficial cells of the conjunc¬ 
tiva itself ; they are arranged in pairs, which are generally 
aggregated together. The gonococcus is said (1) to be 
absent in some of the milder forms of infantile ophthalmia; 
(2) when cultivated to be capable of producing purulent 
( 101 ) 




102 


CLINICAL DIVISION. 


ophthalmia by inoculation ; (3) to be usually present in the 
vaginal discharge of women whose babies have purulent 
ophthalmia. Gonorrhoea was experimentally produced by 
inoculation with pus from purulent ophthalmia long before 
the days of bacterial pathology. Like gonorrhoea, puru¬ 
lent ophthalmia may occur more than once. It varies 
greatly in severity, but is, on the whole, much worse in 
adults than in infants, perhaps because there is much more 
adenoid tissue in the conjunctiva of adults than of babies 
(Widmark). 

From an examination of the records of 158 cases of puru¬ 
lent ophthalmia in adults occurring in the wards at Moor- 
fields 1 the disease is found to be more common in males than 
in females in the proportion of 126 to 32, and the right eye is 
more frequently attacked than the left. The influence of 
age on the prospect of recovery is very great; early adult 
life is the time when the resistance is greatest; practically 
every eye that was attacked when the patient was over 
forty was lost. The other modifying causes are the dura¬ 
tion of the urethral discharge at the time of the inocula¬ 
tion and the time of beginning treatment; inoculation 
during the later stages of the gonorrhoea led to milder 
attacks in the eye, and the earlier the patient came under 
treatment the better the result. In many of the cases 
there was a history of “weak eyes” before the attack; 
this may have been due to a congestion of the anterior 
part of the eye from the circulation of the gonorrhoeal 
poison in the blood, or to a previous condition of the eye¬ 
lids produced by blepharitis or granular disease. 

The disease sets in from twelve to about forty-eight hours 
after inoculation; in infants the third day after birth is 
almost invariably given as the date when discharge was 
first noticed. Itchiness and slight redness of conjunctiva 


1 Holmes Spicer: Ophthalmic Hospital Reports, vol. xiii. p. 211. 


DISEASES OF THE CONJUNCTIVA. 


103 


soon pass on to intense congestion of conjunctiva, with 
chemosis, tense inflammatory swelling of the lids, great 
pain and discharge. The discharge at first is serous, or 
like turbid whey, but soon becomes more profuse, creamy 
(purulent), and yellow, or even slightly greenish. Dark, 
abrupt ecchymoses are often present. The lids, always 
swollen, hot, and red, in bad cases become very tense and 
dusky. The upper lid hangs down over the lower, and is 
often so stiff that it cannot be completely everted. The 
conjunctiva is succulent and easily bleeds. 

The disease if untreated declines spontaneously, and the 
discharge almost ceases in about six weeks, the palbebral 
conjunctiva being left thick, relaxed, and more or less 
granular. Cicatricial changes, identical with, but less 
severe than, those resulting from chronic granular lids, 
and analogous to those which occur in stricture of the 
urethra, sometimes follow; considerable permanent thick¬ 
ening of the ocular conjunctiva may also occur. 

There is a great risk to the cornea in this disease, partly 
from strangulation of the vessels, partly from the local in¬ 
fluence of the discharge. If within the first two or three 
days the cornea becomes hazy and dull, like that of a dead 
fish, there is great risk that total or extensive sloughing 
will occur. In many of the milder cases ulcers form a 
little below the centre, and rapidly cause perforation. In 
other cases clear, deep ulcers form close to the edge of the 
cornea. There is less risk of ulceration of the cornea in 
the purulent ophthalmia of infants than in that of adults. 
Either one or both eyes may be attacked ; in adults one 
eye often escapes; in infants, where the inoculation occurs 
during birth, both eyes almost always suffer. 

Treatment. If only one eye be affected, and the 
patient be old enough to obey orders, the sound eye must 
be covered with the shield introduced by Dr. Buller; take 
two pieces of India-rubber plaster, one 4the other 4' 


104 


CLINICAL DIVISION. 


square, cut a round window in the middle of each, and 
stick them together, with a small watch-glass inserted into 

Fig. 44. 



Buller’s shield. 


the window. The plaster is fixed by its free border, and 
by other strips, to the nose, forehead, and cheek, and the 
patient looks through the glass; the lower outer angle is 
left open for ventilation; particular attention is to be paid 
to the fastening on the nose. All concerned are to be 
warned as to the risk of contagion and the means of con¬ 
veying it. The essential curative measures are: 1. Fre¬ 
quent removal of the discharge by the free use of weak 
antiseptic or astringent lotions (F. 3, 12, 13, 16, 17, 22). 
Every hour, day and night, the lids are gently opened 
and the discharge removed with soft bits of moistened rag 























DISEASES OF THE CONJUNCTIVA. 


105 


or cotton wool. In adults, where the swelling is often ex¬ 
treme and very brawny, the cleansing must be done very 
gently, lest the congestion and irritability be increased. 

2. Iodoform, at first extensively tried, has, I believe, not 
given satisfaction in this disease. Many surgeons greatly 
prefer weak nitrate of silver (F. 3) to all other remedies. 

3. Strong solutions of nitrate of silver, or the mitigated 
solid nitrate (F. 1 and 2), are of great service in shortening 
the attack and lessening the risks, and, whatever other 
treatment be adopted, they should be used in all severe 
cases unless specially contraindicated. The above-men¬ 
tioned analysis showed the very great superiority of 
strong nitrate of silver (grs. x or xx to 5 j) over all 
other kinds of treatment. A ten- or twenty-grain solu¬ 
tion is brushed freely over the conjunctiva of the lids, 
everted as well as possible, and freed from discharge. If 
the mitigated stick is used, more care is needed; and to 
prevent too great an effect it is to be washed off with 
water, after waiting about fifteen seconds. These strong 
applications must be made by the surgeon. The pain 
caused by them is lessened, and the benefit increased, by 
free bathing with cold or iced water afterward. The 
application is not to be repeated until the discharge, 
which will be markedly lessened for some hours, has 
begun to increase again; once a day is enough in many 
cases. 4. Between the cleansings either warm or cold 
applications; warmth is often preferred by the patient. 
5. In the early stage, in adults, several leeches to the 
temple will give relief, or, if the swelling be very tense, 
we may divide the outer canthus with scissors or knife, 
and thus both bleed and relax the parts at the same time. 
Removal of the ring of conjunctiva which overlaps the 
cornea is valuable when the chemosis is severe. 6. The 
lids should be often anointed with a simple ointment. 

Protargol has lately been substituted for silver in the 


106 


CLINICAL DIVISION 


treatment of purulent conjunctivitis, with excellent results. 
The drug possesses all of the bactericidal properties of the 
silver without causing so much pain. It should be used in 
the strength of from 1 to 5 per cent. 

The following additional precautions are important: 
Strong nitrate of silver applications are unsafe in the 
earliest stage, before free discharge has set in, and also 
in cases where, even later in the disease, there is much 
hard, brawny swelling of the ocular conjunctiva and com¬ 
paratively little discharge; cases, in fact, approaching the 
condition known as diphtheritic ophthalmia. In these, 
either very cold or very hot applications, leeches, cleanli¬ 
ness, and weak lotions should be chiefly relied upon. Ice 
and leeches are seldom advisable for infants. It is of ex¬ 
treme importance to begin treatment very early, for the 
cornea is often irreparably damaged within two or three 
days. The patients, if adults, are often in feeble health, 
and need supporting treatment. Ulceration of the cornea 
does not contraindicate the use of strong nitrate of silver 
if the discharge is abundant. Treatment must be con¬ 
tinued so long as there is any discharge, for a relapse of 
purulent discharge often takes place if remedies are dis¬ 
continued too soon. I once saw hemorrhage continuing 
for some time, without apparent cause, from the conjunc¬ 
tiva of the lid, in a child recovering from purulent ophthal¬ 
mia. Serious conjunctival hemorrhage has been noted by 
Pomeroy and Schmidt-Rimpler. 

The systematic prevention of ophthalmia neonatorum by 
the cleansing and disinfection of the eyes of every infant 
immediately after birth, sometimes preceded by disinfec¬ 
tion of the maternal passages, has been introduced by 
Crede and largely carried out in many lying-in hospitals, 
especially on the Continent. Crede applies a few drops of 
a 2 per cent, solution of nitrate of silver (about 8 grs. to 
3 j) to the conjunctival sac once. Various other agents or 


DISEASES OF THE CONJUNCTIVA. 


107 


weaker solutions of silver have been used. The general 
result of such measures has been to reduce the number 
of cases in an astonishing degree; and as it is calculated 
that about a third of all the blind in Europe have become 
so by the ravages of this disease, considerable importance 
is to be attached to the general adoption of Crede’s prin¬ 
ciple by medical men and mid wives. 1 

Catarrhal Conjunctivitis. Simple Acute Conjunctivitis. 
—This is the most common and best characterized of the 
acute ophthalmias. The disease attains its height very 
quickly, almost always attacks both eyes, and recovery is 
spontaneous in about a fortnight. All stages of life are 
liable, but childhood and early adolescence are especially 
prone to it. The lids are somewhat swollen and red, but 
never tense. Often the conjunctive of the lids is alone 
infected, but in the severer cases the bulbar conjunctiva is 
affected as well. The secretion is usually mucoid in char¬ 
acter, and causes the eyelids to “stick” on awakening in 
the morning; but in other cases it becomes mucopurulent 
and is very abundant. There are often ecchymotic patches 
in the conjunctiva. The cornea seldom suffers. 

The symptoms are often most annoying, preventing 
sleep, those afflicted with it complaining of a sensation of 
sand in the eye, of heaviness of the eyelids, and of the 
secretions excoriating the lids and the surrounding skin. 

The causes are mechanical irritation, from either the 
presence of a foreign body or exposure to wind, dust, or 
smoke. The disease may also accompany the exanthemata, 
or may be found in association with constitutional disorders, 
like typhoid fever, or with disease of some of the surround¬ 
ing structures, such as eczema of the lids and nasal 
catarrh. 

Acute Catarrhal Conjunctivitis .—This is also known as 

1 Particulars and statistics may be found in Edinburgh Medical Journal, 
April, 1883 (Or. A. R. Simpson), and in more recent papers. 


108 


CLINICAL DIVISION. 


acute contagious conjunctivitis , epidemic conjunctivitis, and 
pink eye. This variety is a special form of conjunctivitis, 
and is due to a specific bacillus. Koch isolated this bacil¬ 
lus when studying the acute conjunctivitis of Egypt. 
Weeks discovered it independently in New York, and 
Morax has studied its development in Paris. The pneu¬ 
mococcus of Frankel, which is held by Gifford to be a fre¬ 
quent cause of acute conjunctivitis, according to Parinaud 
and Morax is found but rarely in this disease. 

This form of conjunctivitis is most common in warm 
weather, or perhaps at the change from cold to warm. All 
ages are liable, and both eyes are usually affected. 

In this variety acute symptoms are preceded by a short 
and mild period of incubation. At the end of thirty-six 
hours the entire conjunctiva becomes swollen and injected, 
and minute hemorrhagic areas appear scattered over the 
membrane. The swelling of the conjunctiva is most 
marked in the retrotarsal folds, bulbar chemosis being rare. 
The lids, as a rule, are greatly swollen and glued together 
by the thick, ropy secretion. The eyes feel hot and burn, 
and the sensation of their containing sand is complained 
of. The disease attains its height in three days, and the 
acute symptoms subside in about ten days ; but three weeks 
or more elapse before the conjunctiva regains its normal 
appearance. The prognosis is good, as the cornea is but 
rarely implicated. 

The disease is very contagious, and if care be not taken 
to isolate these already affected the other members of the 
family usually suffer. 

Although the history of its epidemic character will sug¬ 
gest the diagnosis in many cases, recourse must be had to 
the microscope to determine its precise nature. 

Treatment. —In ordinary simple conjunctivitis the re¬ 
moval of the cause, stopping the use of the eyes, protecting 
them from light and dust by dark glasses, and the employ- 


DISEASES OF TIIE CONJUNCT! VA. 


109 


merit of a mild antiseptic wash will be sufficient to attain 
a cure. Ice compresses applied for fifteen minutes, every 
two or three hours, will afford considerable relief to the 
subjective sensations. Careful attention to the health is 
necessary. The patient should not be confined to the 
house, but with a large shade over both eyes should take 
plenty of exercise in fine weather. The eyes should not be 
bandaged in any form of conjunctivitis, and poultices should 
never be employed. If there be not too much irritation 
and swelling of the conjunctiva, and if the secretion be at 
all marked, a weak solution of silver nitrate (gr. ij-v to 
f oj) should be brought in contact with the inflamed con¬ 
junctiva by means of a swab, the effect of this drug being 
immediately neutralized by salt water. The edges of the 
lids should be kept moist with vaseline, and after the acute 
stage has passed zinc sulphate and alum (gr. j to f 3 j) should 
be employed. 

In acute contagious conjunctivitis isolation should be in¬ 
sisted upon and cold compresses maintained constantly 
night and day. The eyes should be flushed repeatedly and 
freed from all discharge with boracic acid solution, and 
silver nitrate applied as in simple conjunctivitis. Gifford 
strongly recommends the employment of zinc chloride (gr. 
j to f 5 j) as a collyrium, claiming for this astringent almost 
specific properties in this affection. Lead acetate (gr. j to 
f 5j), hydrogen peroxide, and formalin (Schering’s solution, 
1 : 500 to 1 : 200) have also been employed. 

Parinaud has described a rare form of conjunctivitis due 
to infection of animal origin, probably corresponding to 
the lymphoma of the conjunctiva of Goldzieher. In addi¬ 
tion to swelling of the lids and mucopurulent discharge, 
large polypoid granulations appear upon the conjunctiva, 
especially in the retrotarsal folds. Usually but one eye is 
affected, and the lymphatic glands of the same side may 
suppurate. No microorganism has been isolated. The 


110 


CLINICAL DIVLSION. 


disease usually lasts several months, but complete recovery 
is attained. In a case of this nature occurring in a patient 
with Malta fever, the Editor caused the disappearance of 
the granulations by the prolonged use of alum and silver 
nitrate. Surgical removal of the polypoid masses is not 
advised. 

Follicular conjunctivitis. This occurs generally in chil¬ 
dren or young adults, and is characterized by the forma¬ 
tion of small, clear elevations, consisting of adenoid tissue, 
in the conjunctiva of the lower lid; in some cases they 
are present also in the retrotarsal fold of the upper lid. 
These granulations often give rise to no symptoms, and are 
only part of a general tendency to adenoid enlargement. 
They occur mainly as the result of overcrowding, living in 
unventilated rooms, or are due to the overuse of atropine. 
This condition may have no significance, but it undoubtedly 
predisposes the patient to acute attacks of conjunctivitis of 
various kinds, either of the muco-purulent or granular 
varieties. 

Some forms of acute conjunctivitis, with little or no dis¬ 
charge, are seen both in children and adults, which do 
not conform to the above types, and are of comparatively 
slight importance. Many such appear to depend on changes 
of weather or exposure to cold, and are complicated with 
phlyctenula. A few are distinctly rheumatic. The con¬ 
junctiva is involved more or less in herpes zoster of the 
ophthalmic division of the fifth nerve, in erysipelas of the 
face, in the early stage of measles, and slightly in eczema 
of the face. Slight degrees of chronic conjunctivitis are 
set up by various local irritants, dust, smoke, cold wind, 
etc., and by the strain attending the use of the eyes with¬ 
out glasses in cases of hypermetropia. Mention must be 
made of the cases sometimes seen in children, where an 
ophthalmia appears to form part of an impetiginous or 
herpetic eruption on the face, with which it is simulta- 


DISEASES OF THE CONJUNCTIVA. 


Ill 


neons. These again differ from the more common cases, in 
which the lids, cheek, and lining membrane of the nose 
are irritated into an eruption by tears and discharge from 
a pre-existing conjunctivitis. 

Muco-purulent ophthalmia of any kind becomes a very 
important affair if it breaks out in schools or armies, etc., 
where granular disease of the eyelids is prevalent (p. 113). 

Membranous and diphtheritic ophthalmia. In a few 
cases of ophthalmia, either purulent or muco-purulent, 
the discharge adheres to the conjunctiva in the form of 
a membrane, membranous or croupous ophthalmia. Still 
more rarely, in addition to membrane on the surface, the 
whole depth of the conjunctiva is stiffened by solid exuda¬ 
tion, which much impairs the mobility both of the lids and 
eyeballs, and, by compressing the vessels, prevents the form¬ 
ation of free discharge, and places the nutrition of the 
cornea in great peril. It is to the latter cases that the 
term diphtheritic has been limited by most authors; but 
we find many connecting links between the two types, and 
between each of them and the ordinary purulent and 
muco-purulent cases. 

It is of much consequence in practice, both for prognosis 
and treatment, to recognize the presence of membranous 
discharge and of solid infiltration in any case of ophthal¬ 
mia ; for the liability to severe corneal damage is much 
increased by either of these conditions, especially by the 
latter. The membrane may cover the whole inside of the 
lids, or it may occur in separate, or in confluent patches; 
it often begins at the border of the lid, and is seldom found 
on the ocular conjunctiva. It can be peeled off, the con¬ 
junctiva beneath bleeding freely unless infiltrated and solid ; 
in the latter case the membrane is more adherent, the con¬ 
junctiva is of a palish color, and scarcely bleeds when ex¬ 
posed, and there is little or no purulent discharge. In most 
cases the solid products, whether membrane or deep infil- 


112 


CLINICAL DIVISION. 


tration, pass after some days into a stage of liquefaction, 
with free purulent secretion. In rare cases the membrane 
forms and reforms for months. As regards cause : 1. Very 
rarely the process creeps up to the conjunctiva from the 
nose in cases of primary diphtheria, or is caused by inocu¬ 
lation of the conjunctiva with membrane; while in a few 
the ophthalmia forms the first symptom of general diph¬ 
theria, or of masked or anomalous scarlet fever. 2. More 
commonly it is part of a diphtheritic type of inflammation 
following some acute illness. 3. It may be caused by the 
overuse of caustics in ordinary purulent ophthalmia. 4. It 
may be due to contagion, either from a similar case or from 
a purulent ophthalmia, or a gonorrhoea, the diphtheritic 
type depending on some peculiarity in the health or tissues 
of the recipient. Membranous and diphtheritic ophthalmia 
are seen most often in children from two to eight years old, 
less commonly in adults and infants. It is more common in 
North Germany than in other parts of Europe, but severe 
and even fatal cases are well known in our own country. 
In two cases I have seen the same condition attack the 
skin of the eyelids and cause sloughing patches. 

The Klebs-Loffler bacillus is present in the secretion as 
well as other microorganisms, such as staphylococci, strep¬ 
tococci, and non-virulent Xerosis bacilli. 

Treatment. In treatment the cardinal point is not to 
use nitrate of silver in any form when there is scanty dis¬ 
charge and much solid infiltration of the conjunctiva. 
The agents to be relied upon are (1) either ice or hot 
fomentations—ice, if it can be used continuously and well; 
fomentations, to encourage liquid exudation and determi¬ 
nation to the skin if the cold treatment cannot be carried 
out, or fails to make any impression on the case ; (2) leeches, 
if the patient’s state will bear them; (3) great cleanliness. 
The presence of membrane is no bar to the use of caustics, 
provided that the conjunctiva is succulent, red, and bleeds 


DISEASES OF THE CONJUNCTIVA. 


113 


easily. Mr. Tweedy strongly advises quinine lotion used 
very frequently (F. 21). The constitutional treatment 
with antitoxin has yielded distinctly favorable results. 
Standish found that the injections should be repeated as 
often as every sixteen hours. 

Granular ophthalmia (trachoma) is a very important 
malady, characterized by slowly progressive changes in 
the conjunctiva of the eyelids, in consequence of which 
this membrane becomes thickened, vascular, and rough¬ 
ened by firm hemispherical elevations, instead of being 
pale, thin, and smooth. The change usually begins in the 
conjunctiva of the lower lid, extending to the submucous 
tissue of both lids at a later period, and giving rise to the 
growth of much organized new tissue in the deep parts of 
the conjunctiva. This tissue is afterward partly absorbed 
and partly converted iuto dense, tendinous scar, which by 
very close shrinking often gives rise to much trouble. It 
is stated by Reid and others that trachoma follicles come 
to the surface, open, discharge their contents, and leave 
minute ulcers ; but it cannot be said clinically that trachoma 
is an ulcerative disease, and the prominences are not “ gran¬ 
ulations ” in the pathological sense. 1 There have been, and 
still are, extraordinary differences of opinion as to the 
origin and nature of the “granulations” or “trachoma 
bodies ” in this disease. The latest researches favor the 
view that they are derived from natural lymphatic fol¬ 
licles. Fig. 45 shows a section through some recent 
trachoma bodies. 

The disease shows itself in two forms: 

(a) The papillae undergo considerable enlargement with¬ 
out the appearance of granulations on the surface; the 
conjunctiva covering the tarsus of the upper lid is most 
affected, and appears red and velvety. This is known as 
the papillary form. 

1 I am aware that Raehlmami makes a contrary statement. 

8 


114 


CLINICAL DIVISION. 


(6) The other variety shows itself by the presence on 
both lids of a number of rounded, pale, semi-transparent 
bodies like little grains of boiled sago; the so-called 

Fig. 45. 



Microscopical section through four recent trachoma bodies, “ sago-grain 
granulation,” from the lower lid of a young Irish soldier whose eyes became 
affected in the Egyptian campaigns. The epithelial cells become almost 
indistinguishable from those of the growth where they cover the largest 
nodule. No reticulum can be made out between the cells of which the 
growths are composed. X 14. 

“vesicular,” or “ sago-grain,” or “follicular” granula¬ 
tions (Fig. 46). 

Fig. 46. 



Conjunctiva of upper lid in chronic granular conjunctivitis. (Ault.) 

The two forms of conjunctival affection may occur sepa¬ 
rately, but are usually combined. 

In the earlier stages there may be congestion of the con¬ 
junctiva with a good deal of discharge; after a time the 
discharge lessens, but the granulations remain; in some 
cases the amount of congestion and discharge is never 
great, and there is little to call attention to the eyes. 








DISEASES OF THE CONJUNCTIVA. 


115 


Granular disease is very important because it greatly 
increases the susceptibility of the conjunctiva to take on 
acute inflammation and to produce contagious discharge; 
makes it less amenable to treatment, and very liable to 
relapses of ophthalmia for many years; and often gives 
rise to deformities of the lid and to serious damage of the 
cornea. In crowded poor-law schools we see many cases 
of granular lids in which there is no history of an acute 
attack having ever occurred, but in ordinary practice it is 
rare to see such. 

Chronic granular disease is the result (1) of prolonged 
overcrowding, or rather of long residence in badly ven¬ 
tilated and damp rooms; it used to be very abundant in 
the army and navy, and is still seen in great perfection in 
workhouse schools; (2) a generally low state of health, no 
doubt, increases the susceptibility to it; (3) it is, cceteris 
paribus , more common and most quickly produced in chil¬ 
dren ; (4) certain races are peculiarly liable to suffer— 
e. g., the Irish, the Jews and some other Eastern races, 
and some of the German and French races. The Irish 
and Jews carry it with them all over the world, and trans¬ 
mit the liability to their descendants wherever they live. 
Negroes in America are said by Bennett to be immune to 
trachoma, but his observations have been confined to the 
Southern States; (5) damp and low-lying climates are 
more productive of it than others; thus it is rare in Switz¬ 
erland. Possibly what are now race tendencies may be the 
expression of climatic conditions acting on the same race 
through many generations. It is difficult clinically to 
decide whether the trachoma growths, apart from the dis¬ 
charge, are caused by contagion or by the influence of noil- 
vital causes, such as damp and impure air. They are 
probably due to an increase of normally existing adenoid 
tissue, which acts as a filtering agent to prevent the entrance 
of deleterious matters into the blood. When accompanied 


116 


CLINICAL DIVISION. 


by discharge the disease is contagious ; and it is generally 
held that the discharge from a case of trachoma is specific 
— i. e., that it will give rise by contagion not only to muco¬ 
purulent or purulent ophthalmia, but also to the true gran¬ 
ular disease. 

Sattler, in 1881-82, believed that he had discovered a 
specific microbe for trachoma; his results have been sub¬ 
stantially confirmed by Michel and others, but proof is still 
wanting that the diplococcus of Sattler is the cause of 
trachoma. Most of the micro-organisms hitherto described 
have been found by Ridley in the normal conjunctiva. 

Those who practise in the army, or who have charge of 
such institutions as pauper schools, will find that in prac¬ 
tice the causes of the chronic granular condition are inex¬ 
tricably mixed up with all kinds of facilities for contagion, 
and that it will be necessary to fight against two enemies 
—the causes predisposing to chronic granular disease, and 
the sources of contagious discharge. The former is to be 
combated by improved hygienic conditions, especially by 
free ventilation, dry air, abundant open-air exercise, and 
improvement of the general vigor. The sources of con¬ 
tagion are endless, especially since, as has been stated, 
granular patients are liable to relapses of muco-purulent 
discharge from almost any slight irritation. Frequent 
inspection of all the eyes, rigid separation of all who show 
any discharge or are known as especially subject to re¬ 
lapses, arrangements for washing such as will prevent the 
use of towels and water in common, extreme care against 
the introduction of contagious cases from without—such are 
the chief preventive measures. Extra j^recautions will be 
needed in time of war or famine, or when measles or scar¬ 
let fever are prevalent, or during marches through hot, 
sandy, or windy districts. 

Treatment. The curative treatment, when discharge 
is present, does not differ from that of the acute ophthal- 


DISEASES OF THE CONJUNCTIVA, 


117 


mise already given. The use of strong astringents, solid 
sulphate of copper, or caustics, nitrate of silver in strong 
solution, or in the mitigated solid pencil, or perchloride of 
mercury (F. 11), however, is generally needed in order to 
make much impression on the granular state of the lids. 
The lids being thoroughly everted, are touched all over 
with one or other application, and this is repeated daily, 
or less often ; some experience being required before we 
can decide how often to touch the eyelids in each case. 
By careful treatment on this principle most patients may 
be kept comfortably free from active symptoms, many 
relapses may be prevented, the duration of the disease 
shortened, and the risks of secondary damage to the 
cornea much lessened. Do what we will, however, gran¬ 
ular disease, when well established, is most tedious, and 
fastens many risks and disabilities on its subjects for years 
to come. 

For routine treatment on a large scale nothing is so 
effectual as nitrate of silver, either a ten- or twenty-grain 
solution or the mitigated solid point (F. 1 and 2). But 
silver has the disadvantage of sometimes permanently 
staining the conjunctiva after long use, and in very 
chronic cases I think either sulphate of copper or the 
lapis divinus (F. 5) is to be preferred, especially as the 
patient may sometimes be taught to evert his own lids 
and use it himself. The solid mitigated nitrate of silver 
needs washing off with water at first, but in old cases it is 
often better not to do so. 

Various operative measures have been recommended for 
shortening the duration of the disease; among these are 
the burning of the individual granulations with the gal- 
vano-cautery, and expression or scarification of the granu¬ 
lations. 

The method of expression is carried out by everting the 
lid, grasping it between roller forceps, and squeezing out 


118 


CLINICAL DIVISION. 


the contents of the granulations; it is often combined with 
the application of strong perchloride of mercury to the lid. 

These methods undoubtedly lead to a considerable im¬ 
provement in the condition of the lids, which is sometimes 
permanent; but with the adoption of very severe methods 
there is always a risk of increasing the contraction of the 
conjunctiva. 

Results of Granular Disease. Friction by the 
granulations of the upper lid, Fig. 47, a, especially in 


Fig. 47. 6 



Granular upper lid. a. Granulations, b. Line of scar in typical position, 

parallel with border of lid. 


cases of long standing where some scarring is present (&), 
often causes cloudiness of the cornea, partly from ulcera¬ 
tion, but mainly from the growth of a layer of new and 
very vascular tissue in the superficial layers of the cornea— 
pannus, 1 Fig. 48. In later periods the conjunctiva and 
deeper tissues are shortened and puckered by the scar 
following absorption of the “ granulations,” Fig. 47, b. 
These changes, when severe, often lead to inversion of the 
border of the lid, entropion; when slighter, some or all of 
the lashes may be distorted so as to rub against the cornea, 

1 It is doubtful how far the development of pannus is due to friction, or to 
extension of the trachoma over the sclerotic to the cornea. Trachoma bodies 
may certainly be sometimes seen on the ocular conjunctiva. Raehlmann 
states that the first sign of pannus consists in a collection of lymph-cells in 
the cornea beneath Bowman’s membrane; subsequently a layer resembling 
adenoid tissue is found there containing blood and lymphatic vessels. That 
friction may alter the epithelium is proved by certain cases in which the 
upper half of the cornea loses its polish during a temporary papillary rough¬ 
ening of the upper lid. 








DISEASES OF THE CONJUNCTIVA. 


119 


without actually turning inward, distichiasis, trichiasis; and 
these conditions are often combined with pannus. Pannus 


Fig. 48. 



Section showing layer of new and vascular tissues (pannus) between cpithe« 
lium (Ept.) and cornea (C.). Scl. Sclerotic. C. M. Ciliary muscle. Sch. C. 
Scnlemm’s canal. I. Iris. X about 10 diameters. 


begins beneath the upper lid; its vessels are superficial 
and continuous with those of the conjunctiva, and are dis¬ 
tributed in relation to the parts covered by the lid, not in 
reference to the structure of the cornea, Fig. 49. The 
proper corneal tissue suffers but little except where ulcers 
occur; but when the vascularity is extreme it may soften 
and bulge, even without ulcerating. 

Pannus disappears when the granular lid or the dis- 

FlG. 49. 



Pannus affecting upper half of cornea. 

placement of lashes is cured. Very severe and universal 
pannus is sometimes best treated by the induction of acute 















120 


CLINICAL DIVISION. 


conjunctivitis, the inflammation being followed by oblit¬ 
eration of vessels and clearing of the cornea; this treat¬ 
ment needs judgment and caution. An infusion of the 
seeds known in commerce as “ jequirity” (F. 44), intro¬ 
duced into Europe by de Wecker, is used for the pur¬ 
pose ; it probably depends for its action upon a non¬ 
organ ized ferment such as is found in some other seeds. 
A very acute attack of diphtheritic or purulent ophthal¬ 
mia with much swelling comes on a few hours after the 
infusion has been used, lasts a few days, and is followed 
by a more or less shrinking of the trachoma bodies and of 
the vessels. It occasionally causes glandular swellings in 
the neck and considerable general disturbance. Repeated 
attacks may be induced with safety at intervals of a few 
weeks. Much difference of opinion exists as to the clinical 
value of jequirity, owing to its having been often employed 
too strong and in unsuitable cases; it is not safe unless 
there are vessels on the cornea, and, safety apart, it is 
of little or no use if the conjunctiva be succulent and 
producing pus. It should be reserved for old, dry, gran¬ 
ular lids with more or less pannus, and in such I have 
repeatedly had excellent results from it. Removal of a 
zone of conjunctiva and subconjunctival tissue, syndectomy , 
peritomy , from around the cornea is free from risk and some¬ 
times very beneficial in old cases, which, though severe, 
are not bad enough for inoculation. In old cases of gran¬ 
ular disease, even where no complications have arisen, the 
upper lids often droop from relaxation of the loose con¬ 
junctiva above the tarsal cartilage, and the patient acquires 
a sleepy look. 

For the cure of the displaced lashes and incurved eye¬ 
lids we may : (1) repeatedly pull out the lashes with for¬ 
ceps : (2) extirpate all the lashes by cutting out a narrow 
strip of the marginal tissues of the lid; (3) attempt by 
operation to restore the lashes to their proper direction, 


DISEASES OF THE CONJUNCTIVA. 


121 


Chapter XXII.; (4) employ electrolysis; for a few lashes 
I now use sewing needles, inserting several at a time into 
the hair follicles and passing the current through all at 
once, by means of a broad eyelid forceps. Such opera¬ 
tions well selected and carefully performed give very good 
results; but as the inner surface of the lid continues to 
shorten, and this shortening tends to reproduce the orig¬ 
inal state of things, some of these procedures give only 
temporary relief. 

Chronic conjunctivitis, chiefly of the lower lid, is a com¬ 
mon disease, especially in elderly people. There is more 
or less soreness and smarting, redness and papillary rough¬ 
ness of the inner surface of the lid or of both lids, but 
very little discharge and no trachoma granulations. The 
caruncle is red and fleshy, as it is in all forms of palpebral 
conjunctivitis, and there is often soreness of the lids at the 
canthi. Lapis divinus is one of the best applications, and 
yellow ointment is sometimes useful (F. 5 and 25). 

Lachrymal conjunctivitis. Troublesome chronic conjunc¬ 
tivitis, often complicated by small pustules at the roots of 
the lashes, or by chronic blepharitis, is a common result of 
lachrymal obstruction. Micro-organisms of several kinds 
associated with pus-formation have been found in these 
little abscesses, as well as in pus from the lachrymal sac. 
Palpebral conjunctivitis of long standing, with watering, 
gummy discharge, and more or less blepharitis, should, 
especially if confined to one eye, always lead to the sus¬ 
picion of mucocele or chronic lachrymal abscess. 

The rare disease described as amyloid of the conjunc¬ 
tiva seems scarcely to have been noticed in this country. 
Detailed accounts of its clinical and pathological characters 
may be found in Knapp’s Archives of Ophthalmology , vols. 
x. and xi., and an excellent abstract of one of these papers 
appeared in the Ophthalmic Review for August, 1882. 

Spring catarrh. A peculiar and apparently specific 


122 


CLINICAL DIVISION. 


chronic disease, affecting the conjunctiva of the globe and 
upper lid. In the former situation it takes the form of 
confluent, broad patches of fleshy-looking thickening, of a 
light-brown, pink color, slightly overlapping the edge of 
the cornea for a considerable part of its circumference. 
In the latter situation it occurs as large, pale, flat-topped 
granulations, which are sometimes made to assume poly¬ 
gonal outlines by their pressure upon one another. They 
begin, like trachoma, at the inner and outer end of the 
lid; either variety may occur separately. The disease is 
worse in the warm part of the year, but it lasts in some 
cases many years, and gives but little trouble ; the growths 
on the upper lid do not produce pannus. The thickening 
is said to consist chiefly of epithelium, and not to affect 
the deep tissues. 

Unlike trachoma, it occurs commonly in all classes of 
society, and is probably not contagious: hence its differ¬ 
ential diagnosis in children at school is very important. 
Hitherto it has not been much noticed in America, but 
probably it is not so rare as has been thought. 

Treatment can be only palliative, for the disease does 
not yield readily to therapeutic measures. Non-irritating 
remedies should be applied, as caustics and the stronger 
astringents increase the inflammation. The Editor has 
had excellent results follow frequent cleansing of the con¬ 
junctival cul-de-sacs with a solution of acetic acid (gr. ij— 
viij to the ounce). Operative measures are contraindicated. 

Conjunctivitis from drugs. The local use of atropine 
sometimes gives rise to a peculiar inflammation of the 
conjunctiva and skin of the lid — atropine irritation. The 
conjunctiva of the lids becomes vascular, thickened, and 
even granular, and usually the skin is reddened, slightly 
excoriated, and somewhat shining. This effect of atro¬ 
pine is common in old people. Some persons are very 
susceptible, and cannot bear even a drop or two with- 


DISEASES OF THE CONJUNCTIVA. 


123 


out suffering in some degree. Scopoline, daturine, and 
duboisine cause less irritation, and may be used instead; 
but it is better, if possible, not to use mydriatics at all 
for a few days. An ointment containing lead and zinc 
should be applied to the lids, and zinc or silver lotion to 
the conjunctiva; sometimes glycerine suits better than 
ointment. In susceptible persons I have not found this 
peculiar inflammation prevented, either by the use of 
solutions made with antiseptics or of solutions quite 
freshly made. Eserine sometimes causes identical symp¬ 
toms. Congestion of the conjunctiva has been seen among 
those employed in aniline dye works; conjunctivitis was 
seen by Trousseau in 4 to 5 per cent, of patients treated 
for psoriasis by chrysophanic acid. If continued long 
enough arsenic will in some persons produce redness and 
congestion of the conjunctiva. The action of jequirity is 
described on page 120. 

Ophthalmia nodosa (Saemisch). This singular affection 
is brought about by the irritation of the caterpillar hairs 
introduced into the conjunctival sac. The hairs set up a 
nodular inflammation of the conjunctiva which may ex¬ 
tend to the iris and deeper parts of the eye. The hairs 
should be removed from the conjunctiva, and the inflam¬ 
matory symptoms treated as they arise. 1 

Primary shrinking of the conjunctiva (Pemphigus of the 
Conjunctiva). A very peculiar and rather rare disease, in 
which, with the phenomena of chronic inflammation, the 
whole conjunctiva slowly atrophies and contracts, owing 
to the formation in it of cicatricial tissue. During the 
earlier stages the thickening of the tarsus and the con¬ 
gestion, with scarring of the palpebral conjunctiva, have 
sometimes led to the disease being mistaken for trachoma; 
the two maladies are, however, quite distinct. Finally the 
whole conjunctival sac disappears, and the free borders of 


i See paper by Lawford : Ophthalmic Transactions, vol. xiv. 210. 


124 


CLINICAL DIVISION. 


the lids, fixed closely to the globe, are directly continuous 
with the cornea, which, irritated and dried by exposure 
and want of secretion, becomes opaque and covered by 
crusts—“xerosis.” No treatment seems of any use. 

In some of the cases there has been a history of general 
pemphigus, and reason to believe that the disease of the 
conjunctiva resulted from a modified form of pemphigus 
eruption. 

Blindness from Exposure to Intense Light. Snow-blind¬ 
ness. —Chorio-retinitis localized in the macular region has 
been seen at times in individuals who had observed eclipses 
without proper protecting glasses. The inflammation orig¬ 
inated by this cause is usually quite active and central 
vision is always affected. Long exposure of the eyes to 
the glare from snow gives rise to an acute conjunctivitis 
attended with intense pain, photophobia, and occasionally 
conjunctival hemorrhages. Similar attacks result from 
temporary or even momentary exposure to the intense light 
of the electric arc; this is likely to occur in the operation 
of electric welding, when the thickness of the arc is very 
great. 

The effect on the eye seems to be of the same nature as 
the scorching: or blistering of the skin which is sometimes 
produced under the same circumstances. According to 
Snell, 1 spectacles made up of six layers of glass, alter¬ 
nately red and blue, are worn as a protection to the eyes 
by the workmen engaged in this occupation. 


1 British Medical Association, Bristol, 1894. 


CHAPTER VII. 


DISEASES OF THE CORNEA. 

A. Ulcers and Non-specific Inflammatory Diseases. 

Inflammation of the cornea may be circumscribed or 
diffuse, and, though usually affecting the proper corneal 
tissue, may be limited to the epithelium or either of its 
surfaces. It may be a local process leading to formation 
of pus or to ulceration; or the expression of a constitu¬ 
tional disease, such as inherited syphilis; or it may form 
part, and perhaps only a minor part, of disease involving 
also the deeper part of the eyeball—the iris (kerato-iritis), 
or sclerotic (sclero-keratitis), for example. 

The different varieties of corneal ulceration and sup¬ 
purative inflammation form a very large and important 
contingent of ophthalmic cases. The cornea, although a 
fibrous structure, is further removed from the bloodvessels 
than almost any other tissue, and its delicate surface is 
much exposed ; it is, therefore, extremely susceptible both 
to external irritants and to disturbances of nutrition from 
defective supply, or bad quality, of blood; ulceration of 
the cornea always means deficient vitality. Lastly, its 
surface is so delicate, and its perfect transparency and 
regularity so important, that slight injuries and irritations 
are of more moment here than in any other part of the 
body. 

When inflamed the cornea always loses its transparency. 
If only the anterior epithelium be involved, the surface 
loses its polish, and looks like clear glass which has been 
breathed upon—‘ ‘ steamy/' or finely pitted—a condition 

( 125 ) 


126 


CLINICAL DIVISION. 


occurring in many states of disease. Thickening of the 
epithelium, and, still more, exudation into the corneal tis¬ 
sue, are shown by a white, grayish, or yellowish tint. If 
the corneal tissue be opalescent, while .the surface is at the 
same time “steamy, the term “ground-glass ” gives a good 
idea of the appearance, though to make the simile correct 
the glass ought to be milky throughout, as well as ground 
on the surface. Rapid suppurative inflammation is pre¬ 
ceded by a stage of diffused opalescence ; hence rapid opal¬ 
escence is a sign of imminent danger in such diseases as 
purulent ophthalmia, severe burns, or paralysis of the fifth 
nerve. Fluorescence of the cornea has been seen as the 
result of the use of quinine lotions to the eye, and appears 
to be due to the deposit of crystals of quinine in the cornea. 

Before describing the most important types of corneal 
ulcer, it is convenient to mention the principal changes 
attendant on ulceration of the cornea in general. An ulcer 
of the cornea is preceded by a stage of infiltration, and 
the inflamed spot is generally a little raised. After the 
centre of the spot has broken down into an ulcer, the 
extent, density, and color of the infiltration at its base 
and edges are important guides to its future course. The 
ulcer, when healed, leaves a hazy or opaque spot, leucoma 
if dense, nebula if faint, which is slight and may disappear 
entirely if superficial, but will in part be permanent if the 
ulcer have been deep. These opacities are likely to clear, 
cceteris paribus, in proportion to the youth of the patient; 
time, also, is a very important element, nebulae often con¬ 
tinuing to clear slowly for years; local stimulation aids in 
the removal of the opacities, one of the best applications 
being the ointment of yellow oxide of mercury (F. 25, 26). 
Other modes of local stimulation have been recommended, 
such as tattooing, massage, electrolysis, and the use of various 
powders, especially insufflations of calomel. If this drug be 
dusted into the eye, however, the internal administration of 


DISEASES OF THE CORNEA. 


127 


any of the iodine salts should be discontinued, on account 
of the formation of iodide of mercury, which is extremely 
irritating to the eye. Several successful attempts have been 
made to transplant circular portions of the clear cornea, 
removed from the rabbit by a trephine, to replace portions 
of the human cornea rendered opaque by disease. To do 
this successfully it is necessary to leave behind Descemet’s 
membrane in the diseased cornea (v. Hippie). Ulcers 
which have little or no infiltration often heal slowly, but 
leave a permanent facet or flattening; such facets destroy 
the regular curvature of the cornea, and thus often cause 
more damage to vision than a considerable degree of mere 
clouding. During repair bloodvessels often form and pass 
from the nearest part of the corneal edge to the ulcer, to 
disappear when healing is complete; phlyctenular ulcers, 
however, are vascular from the beginning. Corneal im¬ 
perfections are, of course, most damaging to vision when 
placed over the pupil. 

The chief symptoms of corneal ulceration are (1) photo¬ 
phobia , with its consequence, spasm of the orbicularis, 
blepharospasm; (2) congestion; (3 ) pain. All three symp¬ 
toms vary extremely in degree in different cases. As a 
broad rule, with many exceptions, we may say that intol¬ 
erance of light is worse in children than in adults, worse 
with superficial than with deep ulcers, and worse in per¬ 
sons who are strumous and irritable than in those with 
healthy tissues and good tone. Photophobia should always 
lead to a. careful inspection of the cornea, and we shall 
then sometimes be surprised to fiud how slight a change 
gives rise to this symptom in its severest form. The de¬ 
gree of congestion varies with the seat and cause of the 
ulcer, and with the patient’s age, being usually greatest in 
adults. The visible congestion is, as in iritis, due especi¬ 
ally to distention of the subconjunctival twigs of the ciliary 
zone, Fig. 23, Ant. Oil., and Fig. 2G; but there is often 


128 


CLINICAL DIVISION. 


congestion of the conjunctival vessels as well. In some 
forms of marginal ulcer only those vessels which feed the 
diseased part are congested. Great pain in and around 
the eye often attends the earlier stages of corneal abscess, 
and is common in many acute ulcers; as a symptom, it, of 
course, always needs careful attention ; it is generally re¬ 
lieved by those local measures which are best for the dis¬ 
ease itself. 


Types of Corneal Ulceration. 

1. The simple ulcer begins as a little grayish-white spot, 
at first elevated and bluntly conical, afterward showing a 
minute, shallow crater; the congestion and photophobia 
vary, but are often slight. The ulcer is usually single, 
but it is apt to recur in the same, or the other eye. The 
infiltration often extends into the corneal tissue, and the 
residual opacity remains for a long time, if not perma¬ 
nently. The patients are always badly nourished. In 
most cases the ulcer quickly heals, but now and then the 
infiltration passes into an abscess or a spreading, suppu¬ 
rating ulcer. 

Less commonly we meet with a central ulcer, or a suc¬ 
cession of ulcers, of a much more chronic character, and 
attended with little or no infiltration. After lasting for 
months the loss of tissue is only partly repaired, and a 
shallow depresssion or a flat facet is left, with but little 
loss of transparency. Some of the best examples are seen 
in anaemic or strumous patients with granular lids of long 
standing. 

2. Phlyctenular conjunctivitis (phlyctenular keratitis, pus¬ 
tular ophthalmia, marginal keratitis, strumous ophthalmia, 
lymphatic conjunctivitis). The formation of little pap¬ 
ules, or pustules, on or near the corneal margin is exceed¬ 
ingly common, either independently, or as a complication 
of some existing ophthalmia. Although there are many 


DISEASES OF THE CORNEA. 


129 


varieties and degrees of phlyctenular inflammation in re¬ 
spect to the seat, extent, and course of the disease, the fol¬ 
lowing features are common to all. They show a strong 
tendency to recur during several years; they are seldom 


Fig. 50. 



Phlyctenular conjunctivitis in a scrofulous subject. (Dalrymple.) 


seen in very young children, and comparatively seldom 
after middle life; they occur often in children who have 
a tendency to enlargement of their lymphatic glands; 
blepharitis is often seen in the same patients; the first 
attack often follows closely after an acute exanthem, and 
especially after measles; the cases are much influenced 

o 


130 


CLINICAL DIVISION. 


by climate and weather, and their condition often varies 
extremely from day to day without making either progress 
or regress. 

An elevated spot, like a papule, commonly about the 
size of a small mustard-seed, is seen either on the white 
of the eye near the cornea, or upon, or just within, the 


Fig. 51. 



Phlyctenular ophthalmia, conjunctival form. (Dalrymple.) 

corneal border. It is preceded and accompanied by local¬ 
ized congestion. Its top sometimes becomes as yellow as 
that of' an acne pustule, but more often when seen it has 
become abraded, and aphthous-looking. Pustules at a 
little distance from the cornea, Fig, 51, although gener¬ 
ally larger than those seated on the corneal border, occa¬ 
sion less photophobia, and are more easily cured. Pustules 
at the corneal border, though often very small, cause trou¬ 
blesome and even very severe photophobia; they are 
troublesome in proportion rather to their number than 
their size, and if so numerous as to form a ring around 
the cornea their cure is often very tedious. 

A pustule is always liable, even when it has begun on 
the conjunctiva, to advance as a superficial ulcer on to the 
cornea, though it never extends in the opposite direction 
over the sclerotic. Such a phlyctenular ulcer , if it do not 
stop near the corneal border, will make, in an almost radial 
direction, for the centre, carrying with it a leash of vessels 


DISEASES OF THE CORNEA. 


131 


which lie upon the track of opacity left in the wake of the 
ulcer, Fig. 52. Finally, the ulceration stops, the vessels 
dwindle and disappear, but the path of opacity seldom 
clears up entirely. The term recurrent vascular ulcer is 
used when such ulcers are solitary; but they are often 


Fig. 52. 



Phlyctenular ulcer. (Travers.) 


multiple as well as recurrent, and then, in the end, we find 
the cornea covered by a thin, irregular network of super¬ 
ficial vessels on a patchy, uneven, hazy surface, the so-called 
‘‘phlyctenular pannus. ” 

A common variety of phlyctenular inflammation, aptly 
called marginal conjunctivitis, perhaps allied to the spring 
catarrh of Continental authors, occurs in the form of a 
slight, granular-looking, often vascular swelling, beginning 
as a crescent above or below, but often extending all round 
the edge of the cornea. If the process continue the cornea 
is invaded by a densely vascular, superficially ulcerated, 
and yet thickened zone. It is to be distinguished from a 
deeper variety of marginal keratitis alluded to at p. 141. 

In another variety a single pustule just within the border 

of the cornea ulcerates deeply, becomes surrounded by 

swollen, softened, suppurating tissue, and may perforate; 

such cases are seen in weaklv women and strumous children. 

%/ 

In very rare cases, what appears to be an ordinary conjunc¬ 
tival pustule persists, grows deeply, and may even perforate 



132 


CLINICAL DIVISION. 


the sclerotic in the form of an ulcer ; or it may infiltrate the 
sclerotic and the ciliary body beneath, forming a soft, seini- 
suppnrating tumor, whence the inflammation is likely to 
spread to the vitreous and destroy the eye. Stopping short 
of these extreme results, such a .case forms one type of 
episcleritis. Chapter IX. 

Occasionally a large, sometimes solitary blister forms 
under the anterior corneal epithelium; it rises quickly, 
is attended by severe neuralgic pains, which is often re¬ 
lieved when the vesicle bursts, about a day after the onset. 
The condition is liable to relapse in the same cornea, and 
seems often, though not always, to have its origin in a 
superficial injury. It is sometimes called relapsing bul¬ 
lous keratitis. 

The corneal changes produced by the friction of granu¬ 
lar lids have been considered under that subject. The 
pannus of granular lids usually differs from the “phlyc¬ 
tenular pannus ” just mentioned in being denser and more 
uniform beneath the upper lid, Fig. 49; any doubt is dis¬ 
pelled by everting the lid. But it must be borne in mind 
that ulceration of the cornea often occurs as a complica¬ 
tion of trachomatous pannus. 

3. In old persons a crescentic ulcer sometimes forms in 
the situation of, or actually upon, an arcus senilis. Though 
these cases generally do well, they should be watched, for 
at first they may be indistinguishable from more serious 
forms about to be described. 

In rare cases, the ulcer instead of healing shows a ten¬ 
dency to spread, and gradually to invade the whole cornea, 
the characteristic feature being the undermining of the 
adjacent healthy cornea by the advancing edge of the 
ulcer. Perforation never takes place, but with occasional 
periods of quiescence the whole surface of the cornea is 
invaded, and rendered permanently opaque. This form of 
chronic serpiginous ulcer is more common in tropical coun- 


DISEASES OF THE CORNEA. 


133 


tries than in England, and seems to yield to no treatment 
short of the actual cautery. It is sometimes known as 
rodent ulcer of the cornea. 

4. Acute infective corneal ulcers. Several varieties of dan¬ 
gerous corneal ulcer may be grouped together as probably 
depending upon local infection, and there seems to be no 


Fig. 53. 



Acute serpiginous ulcer of cornea, with crescentic border of infiltration. 

(From a sketch by Dr. Herbert Habershon.) 

doubt that destructive inflammation of the cornea may 
occur in utero. Differing widely in rapidity and depth, 
they argee in being often the result of slight injuries by 
chips of metal, beards of corn, etc., in tending to spread 
at one border while healing at another, in the absence of 
“vessels of repair,” such as are usually formed during the 
healing of other ulcers, and in being often complicated 
with hypopyon. Fig. 54. 

The most important variety is the acute serpiginous ulcer, 
which begins as a gray spot showing slight ulceration, and 
having a sharply cut border, one part of which is more 
densely opaque than the rest , Fig. 53; this infiltrated, ad¬ 
vancing edge is the distinguishing mark of the ulcer. If 
the ulcer have lasted some little time, a portion of its edge, 
usually that nearest the corneal border, will be more or 
less filled up ; in such a state the most conspicuous part of 
the ulcer is crescentic. Fig. 53. Unless quickly checked 
the process often spreads widely, eats deeply, becomes com- 


134 


. CLINICAL DIVISION. 


plicated with iritis and hypopyon, and leads to perforation 
of the cornea. 

Probably many cases of corneal abscess and acute sup¬ 
purating ulcer of less distinct type than the above are, 
like it, due to infection. 

Abscess may occur at any age, but, like serpiginous 
ulcer, is more common in those who are old, underfed, or 
damaged by drink; the simple ulcer of children, however, 
may go on to abscess. Abscess usually forms at the centre 
of the corneal area as a small round raised spot, with great 
pain and congestion; rapidly enlarging, it usually bursts 
forward, leaving a round ulcer covered with lymphy pus, 
but it may perforate the hinder surface of the cornea; 
hypopyon often occurs. The purulent infiltration may 
spread rapidly and destroy almost the whole cornea. 

Hypopyon signifies a collection of pus or puro-lymph at 
the lowest part of the anterior chamber; its upper boun¬ 
dary is usually, but not always level. Fig. 54. It may 
occur with any ulcer, whether deep or not, which is accom¬ 
panied by purulent infiltration of the surrounding cornea; 
or with corneal abscess. The pus may be derived either 
from an abscess breaking through the posterior surface of 
the cornea, or from suppuration of the epithelium covering 
Descemet’s membrane, or from the surface of the iris. 
Simple iritis now and then gives rise to hypopyon. The 
diameter of the anterior chamber being rather greater 
than the apparent diameter of the clear cornea, a very 
small hypopyon may be hidden behind the overlapping 
edge of the sclerotic. In some cases of severe corneal 
suppuration, Fig. 55, a, the pus sinks down between the 
lamellae of the cornea, b. To this condition the term onyx 
is applied, and should be limited, though it is sometimes 
used in other senses. The term, however, may very well 
be discarded. Onyx and hypopyon often co-exist, and 
then the distinction between them can hardly be made 


DISEASES OE THE CORNEA . 


135 


without tapping the anterior chamber. Hypopyon, if 
liquid, will, but onyx will not, change its position if the 
patient lies down; as, however, the pus of hypopyon is 
often gelatinous or fibrinous, this test loses much of its 
value. The distinction can sometimes be made by means 
of oblique illumination, if the cornea in front of an hypo¬ 
pyon remain clear. 


Fig. 54. 



Hypopyon, seen from the 
front, and in section, to show 
that the pus is behind the 
cornea. 


Fig. 55. 



5. Keratomalacia , or primary sloughing of the cornea, 
occurs in young children who are the subjects of grave 
disturbances of nutrition. The first manifestation of the 
affection is a dryness of the conjunctiva, which is no 
longer moistened by the tears; small, triangular patches 
of roughened epithelium, covered with foam, similar to 
those which appear in adults with night-blindness, so 
called xerotic patches, are found on each side of the cor¬ 
nea. The dryness spreads to the cornea, which soon be¬ 
comes dull; this is followed by infiltration and rapid 
destruction of the whole or part of the cornea. In the 
typical cases there is little intolerance of light and no dis¬ 
charge. Keratomalacia appears in England mostly in 





136 


CLINICAL DIVISION. 


hand-reared infants who are insufficiently nourished in 
consequence of unsuitable food or of prolonged diarrhoea; 
it may occur after severe attacks of measles, scarlet fever, 
etc., and frequently comes on during the late stages of not 
very severe ophthalmia neonatorum in children who are the 
subjects of congenital syphilis. It also occurs in breast-fed 
infants in countries where long religious fasts are practised. 
The children are extremely ill, and very frequently die. 

6. Febrile herpes of the cornea appear as small vesicles 
which rupture and leave shallow, punched-out ulcers. 
These sometimes spread generally over the surface, having 
a defined gray, infiltrated edge, but occasionally the ulcera¬ 
tion takes the form of a stem with irregular, broad buds or 
branches, not unlike a liverwort, the disease being super¬ 
ficial from beginning to end and showing no tendency to the 
formation of pus, but spoiling the surface of the cornea— 
dendritic creeping ulcer. 

In rare cases of keratitis beginning as vesicles, small 
filaments are seen adhering to the surface of the cornea; 
these filaments are seen under the microscope to consist of 
a twisted strand made up of epithelial cells and mucus. 
This affection has been called filamentary keratitis (Leber, 
. Nuel, Hess). 

Superficial punctate keratitis (Fuchs) probably also be¬ 
longs to this group. It begins with the symptoms of an 
acute catarrh of the eyes and nose. The corneal changes 
consist of minute gray opacities with a slightly raised sur¬ 
face ; the symptoms of irritation soon disappear, but the 
opacities persist for a longer period. They do not ulcer¬ 
ate, and as a rule the vision is unimpaired. 

7. For Herpes Zoster and Neuro-paralytic Keratitis, see 
Chapter XXIII. 

8. Ulceration of the cornea from exposure occurs in par¬ 
alysis of the orbicularis, in some cases of cicatricial con¬ 
traction of the lid, in severe cases of exophthalmic goitre, 


DISEASES OF THE CORNEA. 


137 


and in persons who are comatose for any length of time. 
It is often possible to avoid this by closing the lids with 
a strip of adhesive plaster, but it may be necessary to pare 
the edges of the lid and stitch them partly together. 

9. A form of keratitis has been observed in those en¬ 
gaged in shucking oysters, to which the name of oyster- 
shuckers ’ keratitis has been given. Randolph, of Baltimore, 
showed that this was not a purely infectious disease, but 
that it was due to mechanical irritation of the cornea by 
the fine particles of lime of the oyster-shell. 

Treatment of Ulcers of the Cornea. The prin¬ 
ciples of local treatment for the various types of corneal 
ulceration .are : 1. To favor healing by keeping the surface 
at rest. 2. To relieve pain, photophobia, and severe con¬ 
gestion. 3. To promote absorption of pus, whether in 
the corneal layers or in the anterior chamber. 4. To 
check the spread of local infection by scraping, actual 
cautery, and antiseptics. 5. By incision to evacuate pus 
between the corneal layers (abscess), or in the anterior 
chamber (hypopyon), when abundant or increasing. 6. 
To stimulate the surface of ulcers which have begun to 
heal, or of indolent ones which are stationary. 7. Counter¬ 
irritation by a seton in certain chronic cases. 8. When 
the corneal ulceration is caused by granular lids, or asso¬ 
ciated with any form of acute ophthalmia, the treatment 
of the conjunctiva is usually more important than that 
of the cornea. 9. Where nutrition is defective, as in 
keratomalacia, it is highly necessary to inquire into and 
remedy any defect in feeding; cod-liver oil is generally of 
great value in such cases. 

Often we have no difficulty in deciding upon the treat¬ 
ment. But in some cases, especially the severer ones, 
much judgment is needed ; and it is sometimes impossible 
to predict with certainty what measures will be best. 

Ulcers of the cornea are so often a sign of bad health 


138 


CLINICAL DIVISION. 


that every care should be bestowed upon the patient’s gen¬ 
eral state. 

Treating the matter clinically, we shall find that local 
stimulation is best for a large number of the cases, as they 
first come under notice, including phlyctenular cases, 
chronic superficial ulcers of various kinds, and even many 
recent ulcers if not threatening to suppurate. As a gen¬ 
eral rule, this plan alone is not suitable when there is much 
photophobia, but exceptions occur, especially in old-standing 
cases. The most convenient remedy is the ointment of 
amorphous yellow oxide of mercury (F. 12 and 13), of 
which a piece about as large as a hemp-seed is to be put 
inside the eyelids once or twice a day. If smarting con¬ 
tinue for more than half an hour the ointment should be 
washed out with warm water; and if the irritability in¬ 
crease after a few days’ use of the ointment, the prepara¬ 
tion must be weakened or discontinued. The same oint¬ 
ment, combined with atropine, gives excellent results in 
cases of superficial ulcer with much photophobia (F. 14). 
Calomel flicked into the eye daily or less often is also an 
admirable remedy. Nitrate of silver in the form of solid 
mitigated stick (F. 1) is useful if carefully applied to large 
conjunctival pustules, and occasionally to indolent corneal 
ulcers; its use, however, needs some skill, and is seldom 
really necessary—solutions of from 5 to 10 grains to the 
ounce may be cautiously used by the surgeon instead of 
the yellow ointment, and are particularly valuable in old 
vascular ulcers and in ulcers with conjunctivitis. When 
in doubt it is best to depend for a few days on atropine 
alone, used once or twice a day. 

In all cases of corneal disease attended with intolerance 
of light the patient is to wear a large shade over both eyes, 
or, better, a pair of “goggles;” a little patch over one 
eye does not relieve photophobia. If the intolerance of 
light be excessive, it is sometimes useful to douche the face 


DISEASES OF THE CORNEA. 


139 


and eyes with a stream of cold water. The patients should 
be allowed to go out; many a child is kept within doors, 
to the injury of its health, who, with suitable protection, 
can go out daily without the least detriment to its eyes. 

In chronic and relapsing cases, with photophobia and 
irritability, where all other methods have had a good trial, 
a seton gives the best results, whether the eye be much 
congested or not. The silk must be very thick, the punc¬ 
tures should be at least an inch apart, and be so placed 
that the scars may be hidden by the hair on the temple 
or behind the ear. The seton is to be moved daily, and if 
acting badly may be dressed with savin ointment; it should 
be worn at least six weeks. Severe inflammation, and even 
abscess, sometimes sets in a few days after the insertion of 
the thread, and in very rare cases secondary bleeding has 
occurred from a branch of the temporal artery. To avoid 
wounding this artery the skin is to be held well away from 
the head. 

Very severe, recent phlyctenular cases are occasionally 
difficult to influence, and remain practically “ blind ” with 
spasm of the lids for weeks. There is seldom any risk, 
provided that the cornea be examined at intervals of a 
few days, and in the end such cases do well. Calomel 
dusted on the cornea sometimes helps more than any other 
local measure, and change of air, especially to the seaside, 
frequently effects a more rapid cure than any local treat¬ 
ment. 

Cases for which the stimulating treatment is suitable 
seldom need the eye to be bandaged, though, as men¬ 
tioned, they often need a shade or goggles. 

The remaining methods are applicable to the severer 
forms of ulceration—the serpiginous ulcer, deep suppu¬ 
rating ulcers, abscess, and generally all ulcers with hypo¬ 
pyon, and all acute ulcers in elderly persons. In many 
cases of severe type, at an early stage, the pain may be 


140 


CLINICAL DIVISION. 


relieved and the ulceration stopped by very hot fomenta¬ 
tions (of water, poppyhead, or belladonna) to the eyelids 
for twenty minutes every two hours, the eye being tied up 
in the internals with a large pad of cotton-wool and ban¬ 
dage, and atropine used two or three times a day; the 
patient must rest, have good food, often with alcohol, and 
take quinine, or bark and ammonia. If, nevertheless, the 
ulceration spread, or a hypopyon form or increase, incision 
of the cornea and the use of topical remedies are called 
for. Of such remedies the best seem to be the actual 
cautery, preceded by scraping with a sharp spoon, and 
followed by iodoform or boric acid. The actual cautery 
may be either the fine galvano-cautery, or a very small 
Paquelin ; the edge of the ulcer is to be well burnt before 
the heat is applied to the floor, and I like to burn a little 
beyond the opaque edge. Instead of the cautery, pure 
carbolic acid or strong solutions of nitrate of silver, 
applied directly to the ulcer, often succeed in checking 
its course. 

Iodoform, which is probably the most useful corneal 
antiseptic, may be used in powder or strong ointment (20 
or 30 gr. to 5 j; F. 30) freely three times a day or more; 
it gives no pain. Boric acid may be used in the same 
way. For dendritic ulcers, absolute alcohol rubbed thor¬ 
oughly into the ulcerated surface, or pure carbolic acid or 
perchloride of mercury of 2 or 4 per cent, strength applied 
with a camel-hair brush, are generally successful. 

Hypopyon, if large, Fig. 54, or increasing, must be let 
out, and on the whole, for most cases, Saemisch’s plan of 
cutting through the cornea quite across the ulcer is the 
best for this purpose, because if there be pent-up pus in 
the cornea this section will allow its removal at the same 
time; the section should be made with a Graefe’s cataract 
knife, Fig. 170, entered with its back toward the lens at 
one border of the ulcer, carried across the anterior cham- 


DISEASES OE THE CORNEA. 


141 


ber, and brought out at the other side of the ulcer. It is 
sometimes an advantage to keep up leakage by reopening 
the wound with a probe for a few days. Corneal section 
also often instantly relieves the severe pain of these cases; 
the section may sometimes be made with equally good 
effect in the lower part of the cornea away from the ulcer. 
If the ulcer have already perforated and the eye be worth 
saving, iridectomy should be done, either by drawing the 
prolapsed iris freely through the perforation and cutting 
it off, or by making an incision in a sound part of the 
cornea. I believe that careful scraping and burning will 
do much to reduce the severity of infective corneal ulcers. 

Some of these ulcers are accompanied by a good deal of 
muco-purulent conjunctivitis, for which a ten-grain solu¬ 
tion of nitrate of silver, painted inside the lower lid with 
a brush about once a day, may generally be used ; its effect 
must be watched, and its employment discontinued if it 
increases irritability. 

Use of atropine and eserine in severe ulcers of the cornea. 
Formerly either atropine, or belladonna lotion, was used 
for nearly every case of severe corneal ulcer. Atropine 
often relieves pain, prevents or lessens iritis, and probably 
lessens engorgement of the vessels of the iris and ciliary 
region ; it may generally be used, sparingly, as an auxil¬ 
iary in suppurating and serpiginous cases, but it tends to 
increase any existing conjunctival inflammation. During 
the last few years eserine has come into use for certain 
cases which would formerly have been treated chiefly by 
atropine. The deep, funnel-shaped, suppurating ulcer 
which sometimes develops from a marginal pustule is the 
most suitable for treatment by eserine, whether compli¬ 
cated with hypopyon or not. Although in a bad case of 
this sort, hot fomentations and the compress are necessary, 
I have seen a certain number of less severe ones recover 
under eserine alone, used about six times a day (F. 39). 


142 


CLINICAL LI VISION. 


Eserine probably acts partly by enlarging the surface of 
the iris and dilating the ciliary arteries, thus favoring ab¬ 
sorption and increasing the nutrition of the cornea. For 
this reason in keratomalacia, where the cornea suffers from 
insufficient nourishment, it should be used without delay. 
The opacity sometimes clears up in a remarkable way 
under its use; possibly, also, it acts locally on the ulcer¬ 
ated surface. There is no clinical proof that eserine lowers 
tension unless the tension has been previously increased, as 
it seldom is in corneal ulcers. Eserine causes congestion 
of the deep vessels of the ciliary region, and after a time 
increases the photophobia and irritability of the eye ; these 
symptoms usually coincide with disappearance of the cor¬ 
neal infiltration and the commencement of vascularization 
of the ulcer, and when this stage is reached the eserine 
should be discontinued. 

The alteruate use of heat and cold for short periods is 
recommended in some obstinate cases of corneal ulceration, 
the object being to improve nutrition by causing frequent 
changes in the quantity and rate of the blood-supply. 

B. Diffuse Keratitis. 

Syphilitic, interstitial , or parenchymatous keratitis. 

In this disease the cornea in its whole thickness under¬ 
goes a chronic inflammation, which shows no tendency 
either to the formation of pus or to ulceration. After 
several months the inflammatory products are either 
wholly or in great part absorbed, and the transparency 
of the cornea restored in proportion. 

The changes in the cornea are usually preceded for a 
few days by some ciliary congestiou and watering. Then 
a faint cloudiness is seen in one or more large patches, and 
the surface, if carefully looked at, is found to be “ steamy.” 
These nebulous areas may lie in any part of the cornea. In 


DISEASES OF THE CORNEA. 


143 


from two to about four weeks the whole cornea has usually 
passed into a condition of white haziness, with steamy sur¬ 
face, of which the term “ ground-glass ” gives the best idea. 
Even now, however, careful inspection, especially by focal 


Fig. 56. 



Interstitial keratitis. 


light, will show that the opacity is by no means uniform, 
that it shows many whiter spots, or large, denser clouds, 
scattered about in the general mist; in very severe cases 
the whole cornea is quite opaque and the iris hidden ; but 

Fig. 57. 



Thickening of cornea and formation of vessels in its layers in syphilitic 
keratitis. Subconjunctival tissue thickened. X about 10 diameters. Com¬ 
pare with Fig. 48. 

as a rule the iris and pupil can be seen, though very imper¬ 
fectly. Fig. 56. In many cases iritis occurs and posterior 
synechise are formed; cyclitis, with deposit in the back of 
the cornea, is a very frequent accompaniment of the cor¬ 
neal affection; in a large proportion of cases of interstitial 







144 


CLINIC A L I) I VISION. 


keratitis there is evidence of early participation of the 
uveal layer in the inflammatory process. Bloodvessels 
derived from branches of the ciliary vessels, Fig. 23, are 
often formed in the layers of the cornea, Fig. 57; they 
are small but set thickly, and in patches; as they are 
covered by a certain thickness of hazy cornea, their 
bright scarlet is toned down to a dull reddish-pink color 
—“salmon patch ” of Hutchinson. The separate vessels 
are visible only if magnified (p. 71), when we see that the 
trunks, passing in from the border, divide at acute angles 
into very numerous twigs, lying close to each other, and 


Fig. 58. 



Vessels in interstitial keratitis. Marginal vascular keratitis. 


taking a nearly straight course toward the centre, Fig. 58. 
These salmon patches, when small, are often crescentic, 
but if large tend to assume a sector-shape. In another 
type the vascularity begins as a narrow fringe of looped 
vessels which are continuous with the loop plexus of the 
corneal margin, Fig. 59, compare Fig. 23, l, and gradually 
extend from above and below toward the centre. The vessels 
in these cases are somewhat more superficial, and the cor¬ 
neal tissue in which they lie is always swollen by infiltra¬ 
tion. This type, which forms a variety of marginal kera¬ 
titis, compare p. 131, usually occurs in syphilitic subjects, 



*- Fig. 59. 

1 








DISEASES OF THE CORNEA. 


145 


but I believe that some of the patients are at the same 
time strumous. A similar condition, sometimes leading to 
secondary glaucoma, occurs now and then in elderly people. 
In extreme cases of either type of vascular keratitis the 
vessels cover the whole cornea, except a small central 
island. 

* The degree of congestion and the subjective symptoms 
in syphilitic keratitis vary very much; as a general rule 
there is but moderate photophobia and pain, but when the 
ciliary congestion is great these symptoms are sometimes 
very severe and protracted. 

The attack can be shortened and its severity lessened by 
treatment; but the disease is always slow, and from six to 
twelve months may be taken as a fair average for its dura¬ 
tion from beginning to end. Very bad cases with exces¬ 
sively dense opacity sometimes continue to improve for 
several years, and may recover an unexpected degree of 
sight. Perfect recovery of transparency is less common, 
even in moderate cases, than is sometimes supposed, but 
the slight degree of haziness which so often remains does 
not much affect the sight. The epithelium usually becomes 
smooth before the cornea becomes transparent, but in severe 
cases irregularities of surface may remain and render the 
diagnosis difficult. Very minute vessels, as in Fig. 58, seen 
by direct ophthalmoscopic examination with a high -f- lens 
(p. 71), nearly straight, and branching at acute angles with 
short, abrupt rectangular bends here and there, are often 
left, and when found are good evidence of previous inter¬ 
stitial keratitis. 

Syphilitic keratitis is almost always symmetrical, though 
an interval of a few weeks commonly separates its onset in 
the two eyes; rarely the interval is several months, a year, 
or even more. It generally occurs between about the ages 
of six and fifteen ; sometimes as early as two and a half 
or three years; in rare instances it may set in after forty ; 

10 


146 


CLINICAL DIVISION. 


many of the very late cases are severe and complicated. If 
it occur very early, the attack is generally mild. Relapses 
of greater or less severity are common. Not only does iritis 
occur with tolerable frequency, but we occasionally meet 
with deep-seated inflammation in the ciliary region, giving 
rise either to secondary glaucoma, or to stretching and 
elongation of the globe in the ciliary zone, or to soften¬ 
ing and shrinking of the eyeball. 1 Dots of opacity may 
sometimes be seen on the back of the cornea at its lower 
part, before the cornea itself is much altered (p. 148); some¬ 
times, too, the interstitial exudation is much more dense at 
the lower part of the cornea than elsewhere. Syphilitic 
keratitis in strumous children often shows more irri¬ 
tability, photophobia, and conjunctival congestion than 
in others; but it is very seldom that ulceration occurs, 
and although in the worst cases the cornea becomes soft¬ 
ened and yellowish, and for a time seems likely to give 
way, actual perforation is one of the rarest events. 
Pannus from granular disease may coexist with syphilitic 
keratitis. 

Treatment. A long but mild course of mercury is cer¬ 
tainly of use. It is customary to give iodide of potassium 
also, and it probably has some influence. If the patients 
be very anaemic, and they often are so, iron, or the syrup 
of its iodide, is more advisable than iodide of potassium 
as an adjunct to the mercury. Locally it is well to use 
atropine by routine until the disease has reached its height, 
on the ground that iritis may be present. Setons, in my 
experience, are seldom of use; but in cases attended by 
severe and prolonged photophobia and ciliary congestion 

1 When the cornea has cleared, ophthalmoscopic signs of past choroiditis, 
Chapter XII., are often found at the fundus. The choroiditis often dates 
much further back than the keratitis, but there is little doubt that it may 
relapse, or occur as an accompaniment of the corneal disease. Chapter 
XXIII. 


DISEASES OF THE CORFEA. 


147 


iridectomy is occasionally followed by rapid improvement; 
this operation, however, is seldom needed or justifiable 
unless there be decided glaucomatous symptoms. When 
all inflammatory symptoms have subsided, the local use of 
yellow ointment or calomel (F. 24 and 25) appears to aid 
the absorption of the residual opacity. 

The form of keratitis above described is caused by in¬ 
herited syphilis. In rare cases it has been seen as the 
result of secondary acquired syphilis. Other cases of dif¬ 
fuse keratitis occur in which syphilis has no share ; but they 
are seldom symmetrical, nor do they occur early in life. 
That diffuse chronic keratitis, affecting both eyes of chil¬ 
dren and adolescents, is, when well characterized, almost 
invariably the result of hereditary syphilis, is proved by 
abundant evidence. A large proportion of its subjects 
show some of the other signs of hereditary syphilis in 
the teeth, skin, ears (deafness), physiognomy, mouth, or 
bones. When the patients themselves show no such signs, 
a history of infantile syphilis in the patient or in some 
brothers and sisters, or of acquired syphilis in one or 
other parent, may often be obtained. 1 That this keratitis 
stands in no causal relation to struma is clear, because the 
ordinary signs of struma are not found oftener in its vic¬ 
tims than in other children, because persons who are de¬ 
cidedly strumous do not suffer from this keratitis more 
often than others, and because the forms of eye disease 
which are universally recognized as “ strumous” (ophthal¬ 
mia tarsi, phlyctenular disease, and relapsing ulcers of 
cornea) very seldom accompany this diffuse keratitis. Illus¬ 
trations of the teeth in inherited syphilis are given in Fig. 
181, Chapter XXIII. 


1 I have found other personal evidence of inherited syphilis in 54 per cent, 
of my cases of interstitial keratitis, and evidence from the family history in 
14 per cent, more—total 68 per cent.; and in most of the remaining 32 per 
cent, there have been strong reasons to suspect it. 


148 


CLINICAL DIVISION 


Other Affections of the Cornea. 

The cornea is more or less involved in several diseases in 
which the primary, or the principal, seat of mischief lies 
in another part of the eye. It is important for purposes 
of diagnosis to compare these secondary or complicating 
affections with the primary diseases of the cornea already 
described. 

In iritis the lower half of the cornea often becomes 
steamy, and more or less hazy. In some cases a number 
of small, separate, opaque dots are seen on the posterior 
elastic lamina (Descemet’s membrane), often so minute 
as to need magnifying (p. 71). These dots are sharply 


Fig. 60. 



Keratitis punctata. (From a sketch by Dr. Herringham.) 

defined, the large ones looking very like minute drops of 
cold gravy-fat, the smallest like grains of gray sand ; in cases 
of long standing they may be either very white or highly 
pigmented. They are generally arranged in a triangle, 
with its apex toward the centre and its base at the lower 
margin of the cornea, the smallest dots being near the 
centre, Fig. 60; but in some cases, sympathetic ophthal¬ 
mitis especially, the dots are scattered over the whole 
cornea. They are of course difficult to detect in propor¬ 
tion as the corneal tissue itself is hazy. 

The term keratitis punctata is used to express this accu¬ 
mulation of dots on the back of the cornea; and by some 
authors is allowed to include also allied cases in which 
small spots with hazy outlines are seen in the cornea 





DISEASES OF THE CORNEA. 


149 


proper. Keratitis punctata is, almost without exception, 
secondary to some demonstrable disease of the cornea, iris, 
or choroid and vitreous. But a few cases are seen, chiefly 
in young adults, where the corneal dots form the principal, 
if not the sole, visible change; the number of such cases 
diminishes, however, in proportion to the care with which 
other lesions are sought (p. 68). Snellen has found micro¬ 
scopically that these dots on Descemet’s membrane consist 
of colonies of bacteria. 1 

It is now and then difficult to say, in a mixed case, 
whether the iritis or keratitis have been the initial change ; 
but when this doubt arises the cornea has generally been 
the starting-point; and with care we are seldom at a loss 
to decide whether the case be one of syphilitic keratitis 
with iritis, of sclerotitis with corneal mischief and iritis, 
or of primary iritis with secondary haze of the cornea. 
See Chapters VIII. and IX. 

Slight loss of transparency of the cornea occurs in most 
cases of glaucoma. The earliest change is a fine, uniform 
steaminess of the epithelium. In very severe, acute cases 
the cornea becomes hazy throughout, though not in a high 
degree. The same haze occurs in chronic cases of long 
standing with great increase of tension, but the epithelial 
“steaminess” often then gives place to a coarser “pit¬ 
ting,” with little depressions and elevations (vesicles), espe¬ 
cially on the part which is uncovered by the lids. 

Conical cornea. In this condition the central part of the 
cornea very slowly bulges forward, forming a bluntly con¬ 
ical curve. The focal length of the affected part of the 
cornea is thereby shortened, and the eye becomes myopic. 
The curvature, however, is not uniform, and hence irregular 
astigmatism complicates the myopia. Chapter XX. 

The disease, which is rare, occurs chiefly in young adults, 


2 Ophtli. Revue, 1894, p. 259. 


150 


CLINICAL DIVISION. 


especially women, and is often associated with chronic dys¬ 
pepsia ; its onset is sometimes dated from a severe, exhaust¬ 
ing illness; it appears to be due to defective nutrition of 
that part of the cornea which is furthest from the blood¬ 
vessels. In advanced cases the protrusion of the cornea 
is very evident, whether viewed from the front or from the 
side, but slight degrees are less easily distinguished from 
ordinary myopic astigmatism. In high degrees the apex 
of the cone, which is situated rather below the centre of 
the cornea, often becomes nebulous. The disease may pro¬ 
gress to a high degree, or stop before great damage has 
been done. Concave glasses alone are of little use; but 
they are sometimes useful in combination with a screen 
perforated by a narrow slit or small, central hole, which 
allows the light to pass only through the centre, or through 
some one meridian, of the cornea. In advanced cases an 
operation must be performed, which, by substituting a con¬ 
tracting cicatrix for the corneal tissue at or near the apex 
of the cone, shall lead to a diminution of the curvature. 
Chapter XXII. 

In buphthalmos (hydrophthalmos) the corneal changes 
are often very conspicuous, although not essential. In this 
rare and very peculiar malady there is a general and 
slowly progressive enlargement of cornea, anterior part 
of sclerotic, and iris, together with extreme deepening of 
the anterior chamber and slight increase of tension. The 
cornea often becomes hazy or semi-opaque. The disease, 
which may perhaps be looked upon as a congenital or in¬ 
fantile form of glaucoma, is either present at birth or comes 
on in early infancy, and usually causes blindness. Opera¬ 
tive treatment generally fails, but eserine is said to be use¬ 
ful. See Glaucoma. 

A rare but peculiar form of corneal disease, generally 
seen in elderly persons, is the transverse calcareous film , 
forming an oval patch of light-gray opacity, which runs 


DISEASES OF THE CORNEA. 


151 


almost horizontally across the cornea. It lies beneath the 
epithelium, and consists of minute crystalline granules, 
chiefly calcareous. 

Arcus senilis is caused by fatty degeneration of the cor¬ 
neal tissue just within its margin. Fig. 61. It first appears 
beneath the upper lid, next beneath the lower, thus forming 
two narrow white or yellowish crescents, the horns of which 
finally meet at the sides of the cornea; it always begins, 
and remains most intense, on a line slightly within the 
sclero-corneal junction, and the degeneration is most marked 
in the superficial layers of the cornea, beneath the anterior 
elastic lamina; in other words, the change is greatest at 

Fig. 61. 



Arcus senilis. (From a sketch by Dr. Herringham.) 

the part most influenced by the marginal bloodvessels. 
Arcus, though seldom seen except in senile persons, is not 
found to interfere with the union of a wound carried 
through it, though the tissue of the arcus is often very 
tough and hard. 

Less regular forms of arcus are seen as the result of 
prolonged or relapsing inflammations near the corneal 
border, whether ulcerative or not. It is generally easy to 
distinguish such an arcus, because the opacity is denser 
and more patchy, and its outlines less regular than in the 
primary form; when arcus is seen unusually early in life 
it is generally of this inflammatory kind, for simple arcus 
is rare below forty. 



152 


CLINICAL I)I VISION. 


Congenital opacity of the cornea sometimes occurs in 
more than one generation or in more than one member of 
a family; one form of congenital opacity closely resem¬ 
bles the arcus senilis in form and situation. 

Opacity of a very characteristic kind is likely to follow 
the use of a lotion containing lead when the surface of the 
cornea is abraded. An insoluble, densely opaque, very 
white film of lead salts is precipitated on, and adheres 
very firmly to, the ulcerated surface; the spot is sharply 
defined, and looks like white paint. If precipitated on a 
deep and much inflamed ulcer, the layer of tissue to which 
the film adheres is often thrown off, but when there is only 
a superficial abrasion or ulcer, the lead adheres very firmly, 
and can only be scraped off imperfectly. But even in the 
latter cases the film is probably after a time thrown off or 
worn off, if we may judge by the fact that nearly all the 
lead opacities which come under notice are comparatively 
new. The practical lesson is never to use a lead lotion for 
the eye when there is any suspicion that the corneal sur¬ 
face is broken. 

The prolonged use of nitrate of silver , whether in a weak 
or strong form, is sometimes followed by a dull, brownish- 
green, permanent discoloration of the conjunctiva, and even 
the cornea may become slightly stained. 


CHAPTER VIII. 


DISEASES OF THE IRIS. 

Iritis. 

Inflammation of the iris may be caused by certain 
specific blood diseases, especially syphilis; or may be the 
exjwession of a tendency to relapses of inflammation in 
certain tissues under the influence largely of climate and 
weather; it often occurs in the course of ulcers and of 
wounds and other injuries of the cornea; also with diffuse 
keratitis and sclerotitis. Iritis also forms a very impor¬ 
tant part of the remarkable and serious disease known as 
sympathetic ophthalmitis. 

Acute iritis, whatever its cause, is shown by a change 
in the color of the iris, indistinctness or “ muddiness” of 
its texture, diminution of its mobility, and the formation 
of adhesions ( j posterior synechias ) between its posterior 
(uveal) surface and the capsule of the lens; there is, be¬ 
sides, in most cases, a dulness of the whole iris and pupil, 
caused by muddiness of the aqueous humor, and partly 
also by slight corneal changes (p. 148). The eyeball is 
congested and the sight usually dimmed. There may or 
may not be pain, photophobia, and lachrymation. 

The congestion is often almost confined to a zone, about 
one-twelfth or one-eighth of an inch wide, which surrounds 
the cornea, its color pink (not raw-red), the vessels small, 
radiating, nearly straight, and lying beneath the conjunc¬ 
tiva, ciliary or circumcorneal congestion , Fig. 26. These 
are the episcleral branches of the anterior ciliary arteries. 
Fig. 23. Quite the same congestion is seen in many other 

( 153 ) 


154 


CLINICAL DIVISION. 


conditions, e. g., corneal ulceration (p. 127); while on the 
other hand, in some cases of iritis, the superficial (conjunc¬ 
tival) vessels are engorged also, especially in their anterior 
divisions, which are chiefly offshoots of the ciliary system. 
We, therefore, never diagnose iritis from the character of 
the congestion alone ; but the disease being proved by the 
other symptoms, the kind and degree of congestion help 
us to judge of its severity. 

The altered color of the iris is due to its congestion 
and the effusion of lymph and serum into its substance; 
a blue or gray iris becomes greenish, a brown one is but 
little changed. The inflammatory swelling of the iris 
also accounts both for the blurring (muddiness) of its 
beautifully reticulated structure, and for the sluggishness 
of movement noticed in the early period. Lymph is soon 
thrown out at one or more spots on its posterior surface, 
and still further hampers its movements by adhering to 
the lens-capsule; and most cases do not come under notice 
till such synechiae have formed. The quantity of solid 
exudation, Avhether on the hinder surface or into the 
structure of the iris, varies much; it is usually greatest 
in syphilitic iritis, when distinct nodules of pink or yel¬ 
lowish color are sometimes seen projecting from the front 
surface, generally close to the pupil. In rare cases pus 
thrown off by the iris into the aqueous subsides and forms 
hypopyon; a corresponding deposit of blood constitutes 
hyphsema. Firm adhesions to the lens-capsule may be 
present without much evidence of exudation into the 
structure of the iris. Exudative changes are usually 
most abundant at the inner ring of the iris, where its 
capillary vessels are far the most numerous. Fig. 62. 

Apparent discoloration of the iris is, however, often due 
entirely to suspension of blood corpuscles, or inflammatory 
products, in the aqueous humor; sometimes this altered 
fluid coagulates into a slightly turbid, gelatinous mass, 


DISEASES OF THE IRIS . 


155 


which almost fills the chamber—“ spongy exudation.” 
The aqueous sometimes becomes yellow without losing 
transparency. 

The tension of the eyeball, usually unaltered in acute 
iritis, may be a little increased; rarely it is considerably 
diminished, and in such cases there are generally other 
peculiarities. 

Fig. 62. 



Vessels of human iris artificially injected ; capillaries most numerous at 
papillary border, and next at ciliary border. 

The condition of the pupil alone is diagnostic in all 
except very mild or incipient cases of iritis. It is sluggisli 
or motionless, and not quite round ; it is also rather smaller 
than its fellow, supposing the iritis to be one-sided, because 
the surface of the iris is increased (and the pupil, there¬ 
fore, encroached on) whenever its vessels are distended (p. 
43). Atropine causes it to dilate between the synechia); 
the synechise, being fixed, appear as angular projections 
when the iris on each side of them has retracted. If there 
be only one adhesion, it will merely notch the pupil at one 
spot; if the adhesions be numerous, the pupil will be cre- 
nated oy irregular. Fig. 63. If the whole pupillary ring, 



156 


CLINICAL DIVISION. 


or still more, if the entire posterior surface of the iris 
be adherent, scarcely any dilatation will be effected; the 
former condition is called annular or circular synechia, 
and its result is exclusion of the pupil; the latter is known 
as total posterior synechia. If the synechise be new and 
the lymph soft, the rejfeated use of atropine will break 
them down, and the pupil will become round; but even 
then some of the uveal pigment, which is easily separable 
from the posterior surface of the iris, often remains behind, 


Fig. 63. Fig. 64. 



Iritic adhesions (posterior synechise) causing irreg- Spots of pigment and 

ularity of pupil. (Wecker and Jaeger.) lymph at seat of former 

iritic adhesions. 

glued to the lens-capsule by a little lymph. Fig. 64. The 
presence of one or more such spots of brown pigment on 
the capsule is always conclusive proof of present or of past 
iritis. The pupillary area itself in severe iritis is often filled 
by grayish or yellowish lymph, which spreads over it from 
the iris; if such exudation becomes organized, a dense 
white membrane or a delicate film, often, however, pre¬ 
senting one or more little clear holes, is formed over the 
pupil —occlusion of the pupil. The iris may be inflamed 
without any lymph being effused from its hinder surface, 
and then the pupil, though sluggish, acting imperfectly to 
atropine, and never dilating widely, will present no poste¬ 
rior synechise nor any adhesion of pigment spots to the 
lens, but it will always be discolored (serous iritis); iritis 
of this kind often occurs with ulceration of the cornea, 
and as a complication of deeper inflammations (p. 170). 





DISEASES OE THE IBIS. 


157 


Pain referred to the eyeball and to the parts supplied by 
the first, and sometimes by the second division of the fifth 
nerve, is common with iritis, especially in the early period. 
It is, however, a very variable symptom, and gives no clue 
to the amount of structural change, being sometimes quite 
insignificant when much lymph is thrown out. The pain 
is seldom constant, but comes on at intervals, is often worse 
at night, and is described as shooting, throbbing, or aching. 
It is commonly referred to the temple or forehead, as well 
as to the eyeball; sometimes also to the side of the nose 
and to the upper teeth. Photophobia and watering are 
generally proportionate to the pain. 

The duration of acute iritis varies from a few days, when 
mild, to many weeks when severe. The defect of sight is 
proportionate to the haziness of the cornea, aqueous, and 
pupillary space, but in some cases is increased by changes 
in the vitreous. Iritis sometimes sets in very gradually, 
causing no marked congestion or pain, but slowly giving 
rise to the formation of tough adhesions, and often to the 
growth of a thin membrane over the pupillary area; in 
some of these cases the iris becomes thickened and tough, 
and its large vessels undergo much dilatation, while in others 
keratitis punctata occurs. See Cyclitis, p. 170; Diseases 
of Cornea, p. 148; and Sympathetic Ophthalmitis, p. 173. 

Permanent results of iritis. Reference has been made 
to the adhesions, which are often permanent, and to the 
spots of uveal pigment on the lens-capsule, which are 
always so; either condition tells a tale of past iritis, and 
is thus a valuable aid to diagnosis. A blue iris which 
has undergone severe inflammation may remain greenish. 
Patches of atrophy may follow severe plastic exudations 
into the iris, and are recognized by their whitish color and 
thinness. Large patches of new pigment occasionally form, 
extending from the pupillary border on to the anterior sur¬ 
face. 


15S 


CLINICAL DIVISION. 


When the pupil is “ excluded” or “ occluded,” the re¬ 
mainder of the iris being free, fluid collects in the poste¬ 
rior aqueous chamber, and by bulging the iris forward, and 
diminishing the depth of the anterior chamber, except at 
its centre, gives the pupil a funnel-like appearance; if the 
bulging be partial, or be divided by bands of tough mem¬ 
brane, the iris looks cystic. Secondary glaucoma is likely 
to follow, and the tension of the globe should, therefore, be 


Fig. 65. 



Diagram to show the result upon the iris of exclusion of pupil (p. 156). 

(From a specimen.) 

carefully noted whenever bulging is present; in not a few 
of these cases, however, we find the eye soft and beginning 
to shrink, the sequel, perhaps, of a glaucomatous state. 
“ Total posterior synechia” always shows a severe, though 
often a chronic, iritis; it is often accompanied by deep- 
seated disease, and followed by opacity of the lens, secon¬ 
dary cataract, and in some cases ultimately the lens becomes 
absorbed. Relapses of iritis are believed to be induced by 
the presence of synechise, even when there is no protrusion 
of the iris by fluid; but their influence in this direction 
has, I believe, been much overrated. 

It must, however, be observed that there is still much differ¬ 
ence of opinion on the point last referred to. The iritis of 


DISEASES OF THE IRIS. 


150 


syphilis is held by some to be liable to recur, and to be by no 
means limited to the secondary stage; and we still often hear 
it stated that iritic adhesions, by preventing free movement of 
the iris, operate as sources of irritation, and thus predispose to 
relapse. I have seldom succeeded in getting a history of recent 
syphilis in cases of recurring iritis, while in a number of cases 
of old iritis, with the history that the attack occurred during 
secondary syphilis years before, I have scarcely found one with 
well-marked history of relapses. On the other hand, I have 
several times seen severe relapses in rheumatic cases after iri¬ 
dectomy had been performed as a preventive. All the evidence 
seems to me to favor the view that recurrences of iritis depend, 
as a rule, upon the constitutional cause of the disease. 

The following are the most important points as to the 
causes of iritis and the chief clinical differences between 
the several forms. 

Constitutional Causes. Syphilis. The iritis is acute ; 
it shows a great tendency to effusion of lymph and forma- 


Fig. 60. 



Nodules occurring in the secondary stage of syphilis, situated at the pupillary 
border of the iris (from a drawing by Mr. W. G. Laws). 


tion of vascular nodules (plastic iritis), most commonly 
situated at the pupillary border of the iris (see Fig. 66) ; 
and the nodules, when very large, may even suppurate— 
it is symmetrical in a large proportion, probably at least 
two-thirds, of the cases. But asymmetry and absence of 
lymph-nodules are common. It occurs almost entirely in 



160 


CLINICAL DIVISION. 


secondary syphilis, either acquired or inherited, and seldom 
relapses. Cases of iritis, associated generally with cyclitis 
and dots on the back of the cornea, also occasionally appear 
many years after syphilitic infection. Its significance is 
thus entirely different from that of the iritis which often 
complicates syphilitic keratitis (p. 142). 

Rheumatism is the cause of most cases of relapsing un- 
svmmetrical iritis. The most common forms of rlieuma- 

%j 

tism which are followed by iritis are the chronic muscular 
and tendinous, and the gonorrhoeal varieties: iritis does 
not occur as a sequel of acute rheumatic fever. See Chap¬ 
ter XXIII. There is but little tendency to effusion of 


Fig. 67. 



Plastic iritis with nodules in the angle of the anterior chamber, not syphilitic. 
Compare with Fig. 66 (from an original drawing by Holmes Spicer). 


lymph, and nodules are never formed, but there is occasion¬ 
ally fluid hypopyon (pp. 134 and 154) ; the congestion and 
pain are often more severe than in syphilitic iritis. An 
attack is usually unsymmetrical, though both eyes com¬ 
monly suffer by turns. It relapses at intervals of months 
or years. Even repeated attacks sometimes result in but 
little damage to sight. 

Gout is apparently a cause in some cases of both acute 
and insidious chronic iritis. It is perhaps doubtful whether 
the gout or the chronic rheumatism from which the same 
patients sometimes suffer is the cause of the iritis. In its 


DISEASES OF THE IRIS. 


161 


tendency to relapse, and to affect only one eye at a time, 
gouty resembles rheumatic iritis. The children of gouty 
parents are occasionally liable to a very insidious and de¬ 
structive form of chronic iritis, with disease of the vitreous, 
keratitis punctata, and glaucoma. Chapter XXIII. 

Chronic iritis (plastic iridochoroiditis ). In a few cases 
symmetrical iritis, of a chronic, progressive, and destructive 
character, is complicated with choroiditis, disease of vitre¬ 
ous, and secondary cataract. These cases, for which it is 
at present impossible to assign any cause, either general or 
local, are chiefly seen in adults below middle life. 

Tuberculosis of the iris occurs in the young either in the 
form of miliary deposits or as a single nodular growth; 
owing to the deep position of the iris, such deposits are 
secondary to tuberculosis in some other part of the body. 

Sympathetic iritis. See Sympathetic Ophthalmitis. 

Local Causes. Injuries. Perforating wounds of the 
eyeball, particularly if irregular, contused, and compli¬ 
cated with wound of the lens, are often followed by iritis, 
and more often if the patient be old than young. If the 
corneal wound suppurate, or become much infiltrated, the 
iritis is likely to be suppurative, and the inflammation to 
spread to the ciliary processes and cause destructive pan¬ 
ophthalmitis. Iritis may follow a wound of the lens-capsule 
without wound of the iris, and with only a mere puncture 
of the cornea. Examples of traumatic iritis from these 
several causes are seen after the various operations for cat¬ 
aract. The iritis following extraction of senile cataract is 
often prolonged, attended by chemosis, much congestion, 
and the formation of tough membrane behind the iris. See 
Cataract. Iritis may also follow superficial wounds and 
abrasions of the cornea, or direct blows on the eye ; but it 
is of great importance, whenever the question of injury 
comes in, to ascertain whether or not there has been a per¬ 
forating wound. Iritis often accompanies ulcers and other 

n 


162 


CLINICAL DIVISION. 


inflammations of the cornea, especially when deep or com¬ 
plicated with hypopyon, or occurring in elderly persons. 
Iritis may accompany deep-seated disease of the eye. 

Treatment. 1. In every case where iritis is present 
atropine is to be used often and continuously, in order to 
break down adhesions already formed, and to allow any 
lymph subsequently effused to be deposited outside the 
ordinary area of the pupil. A strong solution (four grains 
of sulphate of atropine to one ounce of distilled water) or 
an ointment (see Appendix) is to be placed in the conjunc¬ 
tival sac every hour in the early period. Even if the syn- 
echise are, when first seen, already so tough that the atropine 
has no effect on them, it may prevent the formation of new 
ones on the same circle. Atropine also greatly relieves pain 
in iritis, and lessens the congestion, and through these 
means it no doubt helps materially to arrest exudation. 
Mild acute iritis may sometimes be cured by atropine alone. 

2. If there be severe pain with much congestion, three or 
four leeches should be applied to the temple, to the malar 
eminence, or to the side of the nose. They may be repeated 
daily, in the same or smaller numbers, with advantage for 
several days, if necessary; or after one leeching, repeated 
blistering may be substituted. Some surgeons use opiates 
instead of, or in addition to, leeches. Leeches occasionally 
increase the pain. Severe pain in iritis can nearly always 
be quickly relieved by artificial heat, either fomentations or 
dry heat, as hot as can be borne, to the eyelids. To apply 
dry heat, take a piece of cotton-wool the size of two fists, 
hold it to the fire, or against a tin-pot full of boiling water, 
till quite hot, and apply it to the lids; have another piece 
ready, and change as soon as the first gets cool; continue 
this for twenty minutes or more, and repeat it several times 
a day. 1 Paracentesis of the anterior chamber should be 


I owe my knowledge of the value of dry heat to Mr. Liebreich. 


DISEASES OF THE IRIS. 


163 


resorted to in severe iritis if the aqueous humor remain 
very turbid after a few days of other treatment; it may 
be repeated every day or two unless there is marked im¬ 
provement. 

3. Rest of the eyes is very important. Many an attack 
is lengthened out, and many a relapse after partial cure is 
brought on, by the patient continuing at, or returning too 
soon to, work. It is not in most cases necessary to remain 
in a perfectly dark room ; to wear a shade in the room with 
the blinds down is generally enough, provided that no 
attempt be made to use the eyes. Work should not be 
resumed till at least a week after all congestion has gone off. 

4. Cold draughts of air on the eye and all causes of 
“ catching cold ” are to be very carefully avoided by keep¬ 
ing the eye warmly tied up with a large pad of cotton-wool. 

5. The cause of the disease is to be treated, and into this 
careful inquiry should always be made. If the iritis be 
syphilitic, treatment for secondary syphilis is proper, mer¬ 
cury being given just short of salivation for several months, 
even though all the active eye symptoms quickly pass off. 
The rheumatic and gouty varieties are less definitely under 
the influence of internal remedies; iodide of potassium, 
alkalies, colchicum, salicylate of soda, and turpentine, each 
have their advocates; when the pain is severe tincture of 
aconite is sometimes markedly useful; mercury is seldom 
needed, but in protracted and severe cases it may be given 
with advantage. It is sometimes advisable to combine 
quinine or iron with the mercury in syphilis, or to give 
them in addition to other remedies in rheumatic cases. 

6. As a rule, no stimulants are to be allowed, and the 
bowels should be kept well open. 

7. Iridectomy is needed for cases of severe iritis, even 
when there is no increase of tension, if judicious local and 
internal treatment have been carefully tried for some weeks 
without marked relief to the symptoms. It is chiefly in 


164 


CLINICAL DIVISION. 


cases of constitutional origin, either syphilitic or rheumatic, 
and in the iritis accompanying ulcers of the cornea, that 
iridectomy is useful; it is not admissible in sympathetic 
iritis, nor in iritis after cataract extraction. Iridectomy 
has been largely employed to prevent relapses of iritis, but 
the operation has much less effect in this way than has often 
been supposed ; it should not, therefore, be employed until 
the other means of cure have been fairly tried. It must 
be borne in mind that unless iridectomy is necessary, it is 
injurious, by producing an enlarged and irregular pupil 
through which, for optical reasons (p. 22), the patient will 
often not see so well as through the natural pupil, even 
though this be partially obstructed. In regard to all 
methods of local treatment we must bear in mind that 
acute iritis occurs in all degrees of severity, and that the 
mildest cases often need only atropine and rest. 

Traumatic iritis, in the earliest stage, is best combated 
by atropine, continuous cold obtained by laying upon the 
closed eyelids pieces of lint dipped in iced water and 
changed every few minutes, and by leeches. Cold is not 
to be used in any other form of iritis , and is useless even for 
traumatic cases after the first day or so; later, warmth is 
more appropriate. 

Congenital irideremia (absence of iris) is occasionally 
seen, and is often associated with other defects of the eye, 
especially opacities in the lens. 

Pupillary and capsulo-pupillary membranes. In early 
foetal life the capsule of the lens is vascular, supplied with 
blood by the hyaloid artery; when the iris grows in from 
the anterior part of the choroid, and comes in contact with 
the capsule, its vessels anastomose with those of the capsule, 
and the membrane so formed fills the pupil. Normally 
this membrane disappears entirely with the vessels of the 
lens-capsule; sometimes the part attached to the capsule 
only disappears, leaving behind the anterior part of the 


DISEASES OF THE IRIS. 


165 


structure, which is known as the pupillary membrane. In 
this, bands of tissue, resembling that of the iris, run from 
one part of the anterior surface of the iris to another, 
springing from near the pupillary edge. Sometimes the 
whole thickness of the membrane remains, in which case 
bands of tissue pass from the anterior surface of the iris to 
the capsule; this forms the capsulo-pupillary membrane. 
Some of the latter cases have probably been described as 
the remains of intra-uterine iritis. 

Fir,. 68. 



Coloboma of iris. (Sichel.) 

Coloboma of the iris (congenital developmental cleft in 
the iris) gives the effect of a very regularly made iridec¬ 
tomy. It is always downward or slightly down-in, and is 
often, but not always, symmetrical. It occurs in different 
degrees, and sometimes a mere line or seam in the iris indi¬ 
cates the slightest form of the defect. It often occurs with¬ 
out coloboma of the choroid. 





CHAPTER IX. 


DISEASES OF THE CILIARY REGION. 

This chapter is intended to include cases in which the 
ciliary body itself, or the corresponding part of the scle¬ 
rotic, or the episcleral tissue, is the sole seat, or at least the 
headquarters, of disease. From the abundance of vessels 
and nerves in the ciliary body, and the importance of its 
nutritive relations to the surrounding parts we find that 
many of the morbid processes of the ciliary region show a 
strong tendency to spread, according to their precise posi¬ 
tion and depth, to the cornea, iris, or vitreous, and by influ¬ 
encing the nutrition of the lens to cause secondary cataract. 
Although alike on pathological and clinical grounds it is 
necessary to subdivide the class into groups, we may observe 
that the various diseases of this part show a general agree¬ 
ment in some of their more important characters ; thus all 
of them are protracted aud liable to relapse, and in all 
there is a marked tendency to patchiness, the morbid pro¬ 
cess being most intense in certain spots of the ciliary zone, 
or even occurring in quite discrete areas. It is convenient 
to make three principal clinical groups, the differences 
between which are accounted for to a great extent by the 
depth of the tissue chiefly implicated. The most superficial 
may be taken first. 

1. Episcleritis, more correctly scleritis, is the name given 
to one or more large patches of congestion in the ciliary 
region, with some elevation of the conjunctiva from thick¬ 
ening of the subjacent tissues. The congestion generally 
affects the conjunctival as well as the deeper vessels, and 
( 166 ) 


DISEASES OF THE CILIARY REGION. 167 


the yellowish color of the exudation tones the bright blood- 
red down to a more or less rusty tinge, which is especially 
striking at the central, thickest part of the patch. The 
thickening seldom causes more than a low, widely spread 
mound of swelling. 

Episcleritis is a rather rare disease. It occurs chiefly on 
the exposed parts of the ciliary region, and especially near 
the outer canthus; but the patches may occur at any part 
of the circle, and exceptionally the inflammation is diffused 
over a much wider area than the ciliary zone, extending far 
back out of view. The iris is often a little discolored and 
the pupil sluggish, but actual iritis is the exception. There 
is often much aching pain. The disease is subacute, reach¬ 
ing its acme in not less than two or three weeks, and requir¬ 
ing a much longer time before absorption is complete. 
Fresh patches are apt to spring up while old ones are de¬ 
clining, and so the disease may last for months; indeed, 
relapses at intervals, and in fresh spots, are the rule. It 
usually affects only one eye at a time, but both often suffer 
sooner or later. After the active changes have disappeared, 
a patch of the underlying sclerotic, of rather smaller size, 
is generally seen to be dusky as if stained; it is doubtful 
whether such patches represent thinning of the sclerotic 
from atrophy, or only staining; it is but seldom that they 
show any tendency to bulge as if thinned. In rare cases 
the exudation is much more abundant, and a large swelling 
is formed, which may even contain pus; such cases pass by 
gradations into conjunctival phylctenulse, and are generally 
seen in children. 

Episcleritis is seldom seen except in adults, and is more 
common in men than women. Inquiry often shows that the 
sufferer is, either from occupation or temperament, particu¬ 
larly liable to be affected by exposure to cold or by changes 
of temperature. Some of the patients are rheumatic, some 
gouty. Similar patches, but of a brownish, rather translu- 


168 


CLINICAL DIVISION. 


cent appearance, are occasionally caused by tertiary syph¬ 
ilis, acquired or inherited —gummatous scleritis. 

In the treatment, protection by a warm bandage, rest, 
the yellow ointment (F. 25), the use of repeated blisters, 
and local stimulation of the swelling are generally the most 
efficacious. Atropine is very useful in allaying pain. In¬ 
ternal remedies seldom seem to exert much influence except 
in syphilitic cases. Salicylate of soda has been highly 
spoken of by some. Systematic kneading of the eye 
through the closed lids (‘ ‘ massage ”), and scraping away 
the exudation with a sharp spoon, after turning back the 
conjunctiva, have also been recommended, and are worth 
trial. 

2. Sclero-keratitis and sclero-iritis (“ scrofulous sclero¬ 
titis,” “anterior choroiditis”). A more deeply-seated, 
very persistent or relapsing, subacute inflammation, char¬ 
acterized by congestion, of a violet tint, deep scleral con¬ 
gestion, p. 42, abruptly limited to the ciliary zone, and 
affecting some parts of the zone more than others—ten¬ 
dency to patchiness. Early in the case there is a slight 
degree of bulging of the affected part, due partly to thick¬ 
ening ; while patches of cloudy opacity, which may or may 
not ulcerate, appear in the cornea close to, and often con¬ 
tinuous with, its margin ; iritis generally occurs later; pain 
and photophobia are often severe. After a varying interval, 
always weeks, more often months, the symptoms recede ; at 
the focus of greatest congestion, or it may be around the 
entire zone, the sclerotic is left of a dusky color, sometimes 
interspersed with little yellowish patches, and permanent 
haziness of the most affected parts of the cornea remains. 
The disease is almost certain to relapse sooner or later; or 
a succession of fresh inflammatory foci follow each other 
without any intervals of real recovery, the whole process 
extending over months or years. After each attack more 
haze of cornea and fresh iritic adhesions are left. The 


DISEASES OF THE CILIARY REGION. 169 

f- 

sclerotic, in bad cases of some years’ standing, is much 
stained, and may become bulged (ciliary or anterior staphy¬ 
loma), and the cornea becomes more opaque and altered in 
curve; the eye is then useless, though but seldom liable to 
further active symptoms. 

The characteristic appearance of an eye which has been 
moderately affected, is the dusky color of the sclerotic, 
and the irregular, patchy opacities in the cornea, Fig. 69, 
which are often continuous with the sclerotic. The disease 
does not occur in children, nor does it begin late in life; 
most of the patients are young or middle-aged adults, and 
unlike the former variety, most are women. It is not asso- 


Fig. 69. 



Relapsing sclero-keratitis. (From nature.) 

ciated with any special diathesis or dyscrasia, but generally 
goes along with a feeble circulation and liability to “ catch 
coldin some cases there is a definite family history of 
scrofula or of phthisis. Predisposed persons are more likely 
to suffer in cold weather, or after change to a colder or 
damper climate, or after any cause of exhaustion, such as 
suckling. 

Treatment is at best but palliative. Local stimulation 
by yellow ointment or calomel is very useful in some cases, 
particularly in those which verge toward the jdilyctenular 
type. In the early stages, especially when the congestion 
is very violent and altogether subconjunctival, atropine 




170 


CLINICAL DIVISION. 


often gives relief, and it is, of course, useful for the iritis. 
Repeated blistering is also to be tried, though not all cases 
are benefited by it. I have not seen much benefit from 
setons. Warm, dry applications to the lids are, as a rule, 
better than cold. Mercury, in small and long-continued 
doses, is certainly valuable when the patient is not anaemic 
and feeble, but it is to be combined with cod-liver oil and 
iron. Protection from cold and bright light by “ goggles ” 
is a very important measure, both during the attacks and 
in the intervals between them. There is no rule as to sym¬ 
metry; both eyes often suffer sooner or later, but some¬ 
times one escapes while the other is attacked repeatedly. 
Transition forms occur between this disease and episcleritis. 

3. Cyclitis with disease of vitreous and keratitis punctata 
(“ serous cyclitis,” chronic serous iridochoroiditis, “ serous 
iritis ”). A small but important series of cases, in which 
there is congestion, as in mild iritis, and dulness of sight, 
but usually no pain or photophobia. It has been found by 
Treacher Collins that the ciliary body in addition to its 
other functions performs the part of a secreting gland con¬ 
cerned in the nutrition of the vitreous body and in the 
elaboration of the aqueous fluid. When this gland is dis¬ 
eased it gives rise to exudation into the vitreous, and to a 
turbidity of the aqueous from which are deposited the dots 
on the cornea which are commonly known as keratitis punc¬ 
tata. Flocculi are found in the anterior part of the vitre¬ 
ous, or numerous small dots of deposit are seen on the 
posterior surface of the cornea, keratitis punctata, Fig. 
60; the anterior chamber is often too deep, and insidious 
iritis often follows. Patches of recent choroiditis, Chapter 
XII., are sometimes to be seen at the fundus. In bad cases 
buff-colored masses of deposit form in the lower part of the 
angle between iris and cornea; or distinct nodules may be 
present on the iris near its periphery, but not, as in syph¬ 
ilitic iritis, at the pupillary border, Fig. 61. Persistence, 


DISEASES OE THE CILIARY REGION. 


171 


variability, and liability to relapse are almost as marked 
here as in other members of the cyclitic group. The ten¬ 
sion is often slightly augmented at the beginning, but 
usually becomes normal again. Sometimes, however, the 
eye passes into a permanent state of chronic glaucoma, 
probably from blocking of the ligamentum pectinatum 
with cells (see Glaucoma); but usually the final condition 
in bad cases depends on the extent of the iritic adhesions, 
for when the synecliise are numerous and tough, and the 
iris is much altered in structure, or the pupil blocked by 
exudation, secondary glaucoma is likely to arise from im¬ 
prisonment of fluid behind the iris, Fig. 65. When seen 
quite early the diagnosis will probably be “ serous iritis,” 
or “ ciliary congestion,” unless the eye be carefully exam¬ 
ined ; for the pupil is generally free in all parts, or shows, 
at most, one or two adhesions after atropine has been used. 
In a few cases the punctate deposits on the back of the 
cornea constitute almost the only objective change, but 
these are rare. The refraction sometimes beomes tempo¬ 
rarily myopic in serous cyclitis. 

The cases occur in adolescents or young adults, and the 
disease is often sooner or later symmetrical. Many mild 
cases recover perfectly, and in most others the final result 
is satisfactory. In respect to cause, there is strong reason 
to believe that many of these cases are the result of gout in 
a previous generation, the patient himself never having 
had the disease (Hutchinson.) The disease seems often to 
be excited in predisposed persons by prolonged overwork 
or anxiety, combined with underfeeding or defective assim¬ 
ilation ; the patients often describe themselves as delicate; 
some are phthisical. On the other hand, in some of the 
worst cases, leading to secondary cataract, and ultimately 
to shrinking of the eyes (p. 161), the patient appears to be 
from first to last, in good health, and free from any ascer¬ 
tainable morbid diathesis. 


172 


CLINICAL DIVISION. 


Treatment. In the treatment prolonged rest of the 
eyes is important. Atropine is usually necessary, but if 
there be increase of tension its effect must be carefully 
watched, and in cases where there are no iritic adhesions, 
eserine may have to be substituted. If the increase of 
tension keeps up, and seems to be damaging the sight, 
iridectomy is necessary. Small doses of iodide of potas¬ 
sium and mercury appear to be useful in the earlier stages, 
given with proper precautions, and accompanied by iron 
and cod-liver oil. Change of climate would probably often 
by very beneficial. In the worst cases, where the changes 
are like those resulting from sympathetic ophthalmitis, no 
treatment seems to have any effect. 

Cases of acute inflammation are occasionally seen in 
which most of the symptoms resemble those of acute iritis, 
but with the iris so little affected that it is evidently not 
the headquarters of the morbid action. The tension may 
be much reduced, while repeated and rapid variations, 
both in sight and objective symptoms, occur. Again, some 
cases of syphilitic inflammation, which are classed as syph¬ 
ilitic “ iritis,” might be more correctly called “ cyclitis.” 
In some cases of heredito-syphilitic keratitis there is much 
cyclitic complication (p. 145), and this is always difficult 
to treat. 

Plastic inflammation of the ciliary body, following injury, 
traumatic iritis or iridocyclitis, is the usual starting-point of 
the changes which set up sympathetic inflammation of the 
fellow-eye ; the tension is often lowered, and the symptoms 
are subacute. The onset of purulent traumatic cyclitis ( pan¬ 
ophthalmitis ) is signalized by congestion, pain, chemosis and 
swelling of lids, and the appearance of opacity at the 
wound. The inflammation quickly spreads to the iris, 
ciliary body, and vitreous; and then to the capsule of 
Tenon and the muscles, so that the eye becomes glued to 
the surrounding parts and fixed. If the lens be trans- 


DISEASES OF THE CILIARY REGION. 173 

parent a yellow or greenish reflection is, after a few days, 
sometimes seen behind it, indicating the presence of pus 
in the vitreous humor; but usually the cornea and aqueous 
are too turbid, even should the lens be clear, to allow deep 
inspection. Suppurative panophthalmitis occasionally sets 
in acutely and without apparent cause in eyes which have 
long been blind from corneal disease or from glaucoma. It 
may also occur in pysemia, Chapter XXIII. See also 
Pseudo-glioma. 

Sympathetic Irritation and Sympathetic 

Ophthalmitis. 

Certain morbid changes in one eye may set up either 
functional disturbance or destructive inflammation in its 
fellow. The term sympathetic irritation is given to the 
former, and sympathetic ophthalmitis, or ophthalmia, to the 
latter. Though these conditions may be combined, they 
more often occur separately, and it is very important to 
distinguish between them. 

Although at present the exact nature of the changes 
which precede sympathetic inflammation is unknown, 
and their path has not been fully traced out, we are 
sure (1) that the changes start from the region most 
richly supplied with vessels and nerves, viz., the ciliary 
body and iris ; (2) that the first changes recognized by the 
surgeon in the sympathizing eye are generally in the same 
structures ; (3) that the exciting eye has nearly always been 
wounded, and in its anterior part, and that plastic inflam¬ 
mation of its uveal tract is always present; (4) that inflam¬ 
matory changes have in some cases been found in the ciliary 
nerves, and in the coverings of the optic nerve, of the 
exciting eye. 

Within the last few years the hypothesis of transmission 
along the ciliary nerves, which had many adherents, has 


174 


CLINICAL DIVISION. 


been almost given up in favor of the theory of infection. 
Deutschmann has shown (1882-84) that the introduction 
of certain septic organisms into the interior of the eyeball, 
in rabbits, is followed by acute inflammatory changes in the 
other eye; and Gifford (1886), and others more recently, 
have obtained results which tend to confirm the infection 
theory. Most of Deutschmann’s subjects died in a few 
days, and though in many of them the ocular changes were 
those of inflammation traceable along the optic nerve- 
sheaths of the “exciting” eye, by way of the chiasma, 
and down the optic nerve to the optic disk of the “ sym¬ 
pathizer,” still in one or two the morbid process had spread 
to the vitreous and uveal coat. Berlin 1 had previously sug¬ 
gested that the second eye was infected by a special organ¬ 
ism which could flourish only in the eye-tissues, and which 
was carried by the blood from the first eye; and Hutchin¬ 
son 2 afterward independently propounded a nearly identical 
view. Though there are difficulties to be explained and 
gaps to be filled in our knowledge before the infection 
theory in any form can be accepted, yet at the present time 
it claims more and stronger adherents than any other; and 
the difficulties are perhaps not greater than for any other 
theory. 

In almost every case sympathetic inflammation is set up 
by a perforating wound, either accidental or operative, in 
the ciliary region of the other eye— i. e., within a zone, 
nearly a quarter of an inch wide, surrounding the cornea. 
The risk attending a wound in this “ dangerous zone” is 
increased if it be lacerated, or heal slowly, or if the iris or 
ciliary body be engaged between the lips of the sclerotic, 
or if the eye contain a foreign body; under all conditions, 
indeed, which make the occurrence of plastic or purulent 
iridocyclitis probable. Sympathetic inflammation may also 


1 Berlin, 1880. 


2 Hutchinson, 1885. 


DISEASES OF THE CILIARY REGION. 


175 


be set up by a foreign body lodged in the eye, whether the 
wound be in the ciliary region or not; by an eye contain¬ 
ing a tumor, perhaps even if the eye has not been perfor¬ 
ated by operation or ulceration ; by a purely corneal wound, 
or a perforating ulcer, if complicated by adhesion of the 
iris, with dragging on the ciliary body. 

Symptoms in the exciting eye. The exciting eye, when 
it is causing sympathetic irritation , generally shows ciliary 
congestion and photophobia, and often suffers neuralgic 
pain. In an eye which is causing sympathetic inflamma¬ 
tion, obvious iritis, often w r ith lowered tension, is usually 
present; but the iritis is often painless and without notice¬ 
able congestion, and thus may easily be overlooked; it is 
especially important to remember that the exciting eye, 
though its sight is always damaged, need not be blind, and 
that under certain circumstances it may in the end be the 
better eye of the two. 

Symptoms in the sympathizing eye. a. Sympathetic irri¬ 
tation. The eye is, in common speech, “ weak” or “ irri¬ 
table.” It is intolerant of light, and easily flushes and waters 
if exposed to bright light, or if much used; the accommo¬ 
dation is weakened or irritable, so that continued vision for 
near objects is painful, or even impossible; and the ciliary 
muscle seems liable to give way for a short time, the patient 
complaining that near objects now and then suddenly be¬ 
come misty for a while. Neuralgic pains, referred to the 
eye and side of the head, are also common. Temporary 
darkening of sight, indicating suspension of retinal func¬ 
tion, and subjective sensations of colored spots, clouds, etc., 
occur in certain cases. Such attacks may occur again and 
again in varying severity, lasting for days or weeks, and 
finally ceasing without ever passing on to structural change. 
Sympathetic irritation is always, and, as a rule, promptly, 
cured by removal of the exciting eye; but occasionally 
the symptoms persist for some time afterward. A condition 


176 


CLINICAL DIVISION. 


which cannot be distinguished from hysterical blindness is 
sometimes seen in the “ sympathizing” eye, but the term 
sympathetic irritation does not then seem suitable. 1 

b. Sympathetic inflammation ( ophthalmitis ). The disease 
may arise out of an attack of “ irritation,” but more com¬ 
monly it sets in without any such warning. It may be 
acute and severe, or so insidious as to escape the notice of 
the patient until well advanced. It is in nearly all cases 
a prolonged and a recurring disease; when once started it 
is self-maintaining, and its course usually extends over 
many months, or even a year or two. In mild cases a good 
recovery eventually takes place, but in a large majority the 
eye becomes blind. The disease usually takes the form of 
a plastic iridocyclitis or iridochoroiditis with exudation 
from the entire posterior surface of the iris, leading to total 
posterior synechia. Its chief early peculiarities are a great 
liability to dotted deposits on the back of the cornea, cloud¬ 
ing of the vitreous by floating opacities, and often neuro¬ 
retinitis ; there is a dusky ciliary congestion with marked 
engorgement of the large vessels which perforate the scle¬ 
rotic in the ciliary region. In acute and severe cases the 
congestion is intense, there is severe pain, photophobia, and 
tenderness on pressure, and the iris, besides being thick, is 
changed in color to a peculiar buff or yellowish-brown, and 
shows numerous enlarged bloodvessels. Attacks of intense 
neuralgia of the fifth nerve characterize some cases. In 
cases of all degrees the tension is often increased, the eye 
becoming decidedly glaucomatous for a longer or shorter 
time. Many dotted opacities appear in the lens, which 
afterward becomes completely cataractous, and in some 
cases is finally quite absorbed. In the worst cases the 
eye finally shrinks, but in many it remains glaucomatous 


1 Mr. Gunn tells me that he has noticed that marked oscillation of the iris 
often occurs when sympathetic irritation is about to give place to inflammation. 


DISEASES OF THE CILIARY REGION. 177 


with total posterior synechia, corneal haze, and more or less 
ciliary staphyloma. In the mildest cases (the so-called 
“serous” form) the disease never goes beyond a chronic 
iritis with punctate keratitis and disease of the vitreous, 
with which neuro-retinitis often, perhaps always, co-exists. 

Sympathetic ophthalmitis generally begins between six 
weeks and about three months after the injury to the excit¬ 
ing eye; very seldom sooner than three weeks— i. e., not 
until time has elapsed for well-marked inflammatory 
changes to occur at the seat of injury. On the other hand, 
the disease may set in at any length of time, even many 
years, after the lesion of the exciting eye. It occurs at all 
ages. Distinct inflammatory changes are probably always 
present in the exciting eye; but, as already stated, these 
may be very slight and difficult of detection. When care¬ 
fully observed, these changes are found to precede by some 
days, if not longer, the onset of structural disease in the 
sympathizing eye, the morbid process apparently taking 
some time to travel from one eye to the other. 

Treatment. By far the most important measure refers 
to prevention. When once sympathetic inflammation has 
begun we can do little to modify its course. The clear 
recognition of this fact leads us to advise the excision 1 of 
every eye which is at the same time useless and liable to 
cause sympathetic mischief— i. e., of all eyes which are 
blind from injury or destructive corneal disease; and to 
give this advice most urgently when the blind eye is already 
tender or irritable, or is liable to become so, when it has 
been lost by wound, and when it is probable that it may 
contain a foreign body. Any lost eye in which there are 

1 Feeling doubtful whether either abscission or optico-ciliary neurotomy 
confers as great safety from sympathetic disease as does excision, I have not 
performed those operations. The more newly revived evisceration has not 
yet been performed often enough for trustworthy conclusions to be drawn on 
this point. 


12 


178 


CLINICAL DIVISION. 


signs of past iritis, even if there be no history of injury, 
is best removed, especially if shrunken. But much judg¬ 
ment is needed if the damaged eye, though irritable and 
likely to cause mischief, still retains more or less sight. 
Every attention must then be paid to the exact position of 
the wound, the evidence as to its depth, the evidence of 
hemorrhage, and especially to the condition of the lens, 
and to the presence of the yellowish haziness behind the 
lens which indicates lymph or pus in the vitreous. The 
date of the injury and the condition of the wound, whether 
healed by immediate union, or with scarring, puckering, 
or flattening, are very important points. Irritation of the 
fellow-eye may set in a few days after the injury; but since 
inflammation very seldom begins sooner than two or three 
weeks, we may, if we see the case early, watch it for a little 
time. Complete and prolonged rest in a darkened room is 
a very important element in the prevention of sympathetic 
irritation and inflammation, and should always be insisted 
on when we are trying to save an injured eye. In rare 
cases sympathetic inflammation sets in after the removal of 
the exciting eye, even after an interval of several weeks— 
a contingency which emphasizes the importance of excising 
every condemned eye at the earliest possible moment. 

When sympathetic ophthalmitis has set in we can do com¬ 
paratively little. 

A. The exciting eye , if quite blind or so seriously dam¬ 
aged as to be for practical purposes certainly useless, is to 
be excised at once, though the evidence of benefit from 
this course is slender. But it is not to be removed if there 
is reason to hope for restoration of useful sight in it; if 
there is simply a moderate degree of subacute iritis, with 
or without traumatic cataract, and with sight proportionate 
to the state of the lens, the eye is to be carefully treated, 
since it may very probably in the end be the better of the 
two (p. 175). 


DISEASES OF THE CILIARY REGION. 


179 


b. The sympathizing eye. The important measures are (1) 
atropine, used very often, as for acute iritis; (2) absolute 
rest and exclusion of light by residence in a dark room 
and with a black bandage over both eyes; (3) repeated 
leeching if the symptoms are severe, or counter-irritation 
by blisters or by a seton in chronic cases. (4) Mercury is 
believed by some to be beueficial. Quinine is sometimes 
giveu. (5) As a rule, no operation is permissible while the 
disease is still active, since iridectomy, performed while 
there are active symptoms, is followed by closure of the 
gap with fresh lymph. Operations in severe cases which 
have become quiet are seldom of use, the eye being gener¬ 
ally then past recovery. 

Prognosis. The prognosis is, as will be gathered very 
grave; even in the mildest cases, when seen quite early, we 
must be very cautious, for the disease often slowly progresses 
for many months. 


CHAPTER X. 

INJURIES OF THE EYEBALL. 

A clear distinction is to be made between contusion 
and concussion injuries, and wounds of the eyeball. 

1. Contusion and concussion injuries. Rupture of the 
eyeball is commonly the result of severe direct blows. The 
rent is nearly always in the sclerotic, either a little behind 
or close to the corneal margin, with which it is concentric; 
the cornea itself is but seldom rent by a blow. The rup¬ 
ture is usually large, involves all the tunics, and is followed 
by immediate hemorrhage between the retina and choroid, 
and into the vitreous and anterior chambers; the lens and 
some of the vitreous often escape; sight is usually reduced 
to perception of light or of large objects. The conjunctiva, 
however, often escapes untorn, and in such a case if the 
lens pass through the rent in the sclerotic, it will be held 
down by the conjunctiva, and form a prominent, rounded, 
translucent swelling over the rupture. The diagnosis of 
rupture is generally easy, even if the rent be more or less 
concealed. The eyeball often shrinks; but occasionally it 
recovers with useful vision. Immediate excision is gener¬ 
ally best when the wound is “ compound but if the con¬ 
junctiva be not torn, aud ocasionally even when it is, we 
should wait a few days until the disappearance of the blood 
from the anterior chamber allows the deeper parts to be 
seen. The treatment is the same as for wounds of the eye. 
When the lens is lying beneath the conjunctiva it should 
( 180 ) 


t 


INJURIES OF THE EYEBALL. 181 

be removed when the sclenil wound has healed, if we de¬ 
cide to save the eye. 

It may here be mentioned that copious hemorrhage, 
accompanied by severe pain, sometimes occurs between the 
choroid and sclerotic as the result of sudden diminution of 
tension, either by an operation, such as extraction of cata¬ 
ract or iridectomy, or by a glancing wound of the cornea. 
Eyes in which this occurs are for the most part already 
unsound and often glaucomatous. 

Blows often cause internal damage without rupture of the 
hard coats of the eye. The iris may be torn from its ciliary 
attachment ( coredialysis ), so that two pupils are formed, 
Fig. 70, or the lens may be loosened or displaced by partial 
rupture of its suspensory ligament, so that the iris, having 
lost its support, will shake about with every movement 


Fig. 70. 



Separation of iris following a blow. 


(tremulous iris'). Such lesions are likely to be obscured for 
a time by bleeding into the anterior chamber and into the 
vitreous. The lens often becomes opaque afterward. De¬ 
tachment of the retina is often found after severe blows, 
which have caused hemorrhage into the vitreous. Blows 
on the front of the eye may cause rupture of the choroid , 
or hemorrhage from choroidal or retinal vessels. These 
changes are found at the central part of the fundus, and if 
the yellow spot is involved visual acuteness is much dam¬ 
aged. The rents in the choroid appear after the blood has 


182 


CLINICAL DIVISION 


cleared up as lines or narrow bands of atrophy bordered 
by pigment, and often slightly curved toward the disk, Fig. 
84. Hemorrhages from the choroidal vessels without rup¬ 
ture of the choroid, usually leave some residual pigment 
after absorption. In an eye predisposed to detachment of 
retina, a blow will sometimes determine its occurrence. 
Paralysis of the iris and ciliary muscle, with partial, some¬ 
times irregular dilatation of the pupil, are often the sole 
results of a blow on the eye; the defect of sight can be 
remedied by a convex lens. Complete recovery is moder¬ 
ately common, the ciliary muscle recovering before the iris. 
Partial dilatation or imperfection of the pupil after a blow 
is sometimes dependent on rupture of the sphincter, one or 
more notches in the pupillary border of the iris indicating 
the seat of the lesion or lesions. For Traumatic Iritis, see 

p. 161. 

Great defect of sight following a blow, neither remedied 
by glasses nor accounted for by blood in the anterior cham¬ 
ber, will generally mean copious hemorrhage into the vitre¬ 
ous, with one or another of the changes just mentioned in 
the retina and choroid. The red blood may sometimes be 
seen by focal light, but often its presence can only be 
inferred from the opaque state of the vitreous. Probably 
in most of these cases the blood comes from the large veins 
of the ciliary body, but sometimes from the vessels of the 
choroid or retina. There may be no external ecchymosis. 
The tension of the globe is to be noted; it is not often 
increased unless inflammation has set in, or the eye has 
been previously glaucomatous, and in some cases it is below 
normal. The prognosis should be very guarded whenever 
there is reason to think, from the opaque state of the parts 
behind the lens, that much bleeding has taken place, or 
that the retina is detached, or when the iris is tremulous or 
partly detached, or if any rupture of the choroid can be 
made out. Blood in the anterior chamber is often com- 


INJURIES OF THE EYEBALL. 


183 


pletely absorbed in a day or two, or even sometimes in a 
few hours; but in the vitreous humor absorption, though 
rapid, is less complete, and permanent opacities are often 
ieft. The use of atropine, the frequent application, during 
the first twenty-four hours, of iced water, or of an evap¬ 
orating lotion to the lids, and occasional leeching if there 
be inflammatory symptoms, will do all that is possible for 
the first week or two after a severe blow with internal hem¬ 
orrhage. If the lens be loosened, it may at any time act 
as an irritating foreign body, or set up a glaucomatous 
inflammation (Dislocation of Lens, p. 210). Now and then 
optic neuritis occurs in the injured eye as the immediate 
effect of the blow. Hemorrhage behind the choroid is 
believed by some to account for certain well-known cases 
in which, after a blow, there is defect of sight without 
visible change, or with localized temporary haze of retina 
(commotio retinae). Temporary myopia or astigmatism 
may also follow a blow on the eye ; they depend on altered 
curvature of the lens, and are sometimes entirely removed 
by paralyzing the ciliary muscle with atropine (see also 
Hysterical Amblyopia). 

2. Wounds, a. Superficial abrasions of the cornea cause 
much pain, with watering, photophobia, and ciliary con¬ 
gestion. They are frequently due to a scratch by a finger¬ 
nail of a baby at the breast. The abraded surface is often 
very small, and shows no opacity; it is detected by watch¬ 
ing the reflection of a window from the cornea, while the 
patient slowly moves the eye. Now and then the symp¬ 
toms return after a long interval of cure. Many, if not 
all, of the cases of relapsing bullae of the cornea seem to 
have originated in a slight superficial injury. 

Minute fragments of metal or stone flying from tools, 
etc., often partly embed themselves in the cornea, foreign 
body on the cornea , and give rise to varying degrees of 
irritability and pain. The fragment soon becomes sur- 


184 


CLINICAL DIVISION. 


rounded by a hazy zone of infiltration, but it remains 
easily visible unless it be very small or covered by mucus 
or epithelium. When in doubt always examine the cornea 
by focal light with magnifying power. 

The pupil is often smaller than its fellow, and the 
color of the iris altered, in cases of superficial injury 
to the cornea, indicating congestion of the iris. Actual 
iritis sometimes occurs, but not unless the corneal wound 
inflame. 

Treatment. After surface injuries a drop of castor 
oil may be applied, and the eye kept closed for the day 
with a pad of wadding and a bandage. Atropine is re¬ 
quired if there be much irritation or threatened iritis. If 
hypopyon appear the case becomes one of hypopyon ulcer. 
For removal of foreign bodies see Operations. 

Foreign bodies often adhere to the inner surface of the 
upper lid; whenever a patient states that he has “ some¬ 
thing in his eye ” and nothing can be found on the cornea, 
the upper lid must be everted and examined. 

Large bodies sometimes pass far back into the upper or 
lower conjunctival sulcus, and lie hidden for weeks or 
months, causing only local inflammation and some thick¬ 
ening of the conjunctiva. Search must be made, if needful, 
with a small scoop or probe whenever the suspicion arises. 
See Orbit. 

b. Burns, scalds, and injuries by caustics, etc. The con¬ 
junctiva and cornea are often damaged by splashes of mol¬ 
ten lead, or by strong alkalies or acids, of which lime, either 
quick or freshly slaked, is the more common. The eyeball is 
not often scalded, the lids closing quickly enough to prevent 
the entrance of steam or hot water. As the full effect in 
such cases is not apparent for some days, a cautious opinion 
should be given in the early stages. 

The effects of such accidents are manifested by (1) 
inflammation of the cornea passing into suppurative kera- 


INJURIES OF THE EYEBALL. 


185 


titis with hypopyon, in bad cases; (2) scarring and short¬ 
ening of the conjunctiva, and in bad cases adhesion of its 
palpebral and ocular surfaces— symblepharon. 

The most superficial burns whiten and dry the surface, 
and in a few hours the epithelium is shed. This is shown 
on the cornea by a sharply outlined, slightly depressed area. 
The surface is clear if the damage be quite superficial and 
recent, but more or less opalescent, or even yellowish, if the 
case be a few days old, and the burn be deep enough to 
have caused destruction or inflammation of the true corneal 
tissue. When there is much opacity it does not completely 
clear, and considerable flattening of the cornea and neigh- 


Fig. 71. 



Burns of conjunctiva. (White-Cooper.) 

boring sclerotic often occurs at the seat of deep and exten¬ 
sive burns. The conjunctival whitening is followed by 
mere desquamation and vascular reaction, or by ulceration 
and scarring, according to the depth of the damage. 

Treatment. In recent cases, seen before reaction has 
begun, a drop of castor oil once or twice a day, a few 
leeches to the temple, and the use of a cold evaporating 
lotion, or of iced water, will sometimes prevent inflamma¬ 
tion. If seen immediately after the accident, the conjunc- 




186 


CLINICAL DIVISION. 


tival sac is to be carefully searched for fragments, or washed 
with very weak acid or alkaline solution if a liquid caustic 
of the opposite character have done the damage. If inflam¬ 
matory reaction be already present, treatment by compress, 
hot fomentations, and the other means recommended for 
suppurating ulcers (p. 141), is most suitable. There is often 
much pain and chemosis. See Operation for Symblepharon. 

c. Penetrating wounds and gunshot injuries. When a 
patient says that his eye is wounded, the first step is to 
examine the seat, extent, and character of the wound, ascer¬ 
tain the interval since the injury, and test the sight of the 
eye; the next to make out all we can about the wounding 
body, and especially whether any fragment has been left 
within the eyeball. 

Very large foreign bodies, such as pieces of glass, some¬ 
times lie for a long time in the eye without causing much 
trouble, the large wound having given exit to the contents 
of the globe, and been followed by rapid shrinking without 
inflammation. 

Treatment. Penetrating wounds are least serious when 
they implicate the cornea alone, or the sclerotic behind the 
ciliary region— i. e., one-fourth inch or more behind the 
cornea. Penetrating wounds of the cornea without injury to 
the iris or lens, and without any prolapse of iris, are rare; 
they generally do very well, and if the case be not seen until 
one or two days after the injury, the wound will often have 
healed firmly enough to retain the aqueous, and it may be 
difficult to decide whether the whole thickness of the cornea 
have been penetrated or not. Wounds of the sclerotic seldom 
unite without the interposition of a layer of lymph; when 
seen early they should, if gaping, clean, and uncomplicated 
by evidence of internal injury, be treated by the insertion 
of fine sutures, which should be passed only through the 
conjunctiva, followed by the use of ice. 

But penetrating wounds are usually very serious to the 


INJURIES OF TIIE EYEBALL. 


187 


injured eye; the iris is frequently lacerated and included 
in the track of the wound; the lens is punctured, and 
becomes swollen and opaque from absorption of the aque¬ 
ous humor (traumatic cataract ); it is liable in its swollen 
state to press on the ciliary processes, and cause grave 
symptoms ; extensive bleeding perhaps takes place into the 
vitreous; within the first few days purulent inflammation 
may destroy the eye. The fellow-eye is, of course, often 
in danger of sympathetic inflammation. Every case has, 
therefore, to be judged from two points of view, the damage 
to the injured eye, and the risk to the sound one; and the 
question whether to sacrifice or attempt to save the former, 
is sometimes very difficult to decide. 

I. In the two following cases the eye should be sacrificed 
at once: 1. If the wound, lying wholly or partly in the 
“ dangerous region,” be so large and so complicated with 
injury to deeper parts that no hope of useful sight remains. 
2. If, even though the wound be small, it lie in the danger¬ 
ous region, and have already set up severe iritis (pp. 161 
and 172). 

II. There is a large class of cases in which it is certain, 
or very probable, that the eye contains a foreign body, 
although the injury is not of itself fatal to sight, and has 
not as yet led to inflammation, or to shrinking, of the 
eye. 

The first question, then, is whether the foreign body can 
be seen; the second, whether or not it is steel or iron, and 
therefore possibly removable by a magnet. A foreign body, 
if lying on or embedded in the iris, the lens being intact, 
should be removed, usually with the portion of iris to which 
it is attached ; if loose in the anterior chamber its removal 
may be difficult. If it can be seen embedded in the lens 
and the condition of the eye be otherwise favorable, a scoop 
extraction may be done in the hope of removing the frag¬ 
ment with the lens; or the lens may be allowed, or by a 


188 


CLINICAL DIVISION. 


needle operation induced, to undergo partial absorption and 
shrinking, so as to enclose the foreign body more firmly, 
and, when subsequently extracted, bring it away. If we 
are certain that the foreign body has passed into the vitre¬ 
ous, whether through the lens or not, and whether by gun¬ 
shot or not, we can seldom save the eye. The foreign body 
can in such a case seldom be seen, but a track of opacity 
through the lens, with blood in the vitreous, or even the 
latter alone, with conclusive history that the wound was 
made by a fragment or a shot, and not by an instrument 
or large body, will generally decide us in favor of excision. 
These rules need some modification when the foreign body 
is of iron or steel, since it is possible in certain cases, by 
means of a strong electro-magnet, to remove such frag¬ 
ments, even when lying in the vitreous. This may be done 
either through the wound of entrance, more or less enlarged, 
or through a fresh wound made where the body is seen, or 
believed to lie. Many forms of magnet have been employed, 
the most successful in their application usually being those 
in which a probe-ended instrument, powerfully magnetized 
by being attached to the core of an electro-magnetic coil, is 
introduced into the eye in search of the body. Haab has 
lately introduced large and very powerful electro-magnets 
into ophthalmic surgery; but, while very efficacious, they 
are not often available except in a large hospital service. 
Though a number of eyes have now been saved with useful 
sight by means of the magnet, it must be remembered that the 
extraction of the foreign body does not ensure the safety 
of the eye ; that the eye may inflame or shrink, and remain 
as potent a source of sympathetic disease as before, espe¬ 
cially so if iritis or threatened panophthalmitis were present 
at the time of operation. 1 Foreign bodies occasionally 

1 Mr. Snell, of Sheffield, who has probably had a larger experience of this 
method than any one else, has published (June, 1883) an excellent mono¬ 
graph, in which all the cases hitherto recorded are given, in addition to his 
own. Hirschberg’s monograph on the subject (1885) brings the subject up to 
later date. 


INJURIES OF THE EYEBALL. 


189 


become embedded at the fundus, beyond the dangerous 
region, and cause no further trouble. In gunshot cases the 
shot often passes out through a counter-opening, and re¬ 
mains without doing harm to the orbit, though the eye is 
destroyed. Occasionally the choroid and retina are dam¬ 
aged by hemorrhage caused by a shot or bullet traversing 
the orbit close to, but without demonstrable lesion of, the 
sclerotic. 

Since the introduction of the Rontgem rays into surgery 
the treatment of eyes containing metallic foreign bodies 
has been revolutionized, as it is now quite feasible by 
means of a series of skiagrams to locate accurately the 
position of the bodies. This being accomplished, its removal 
is comparatively simple. 

III. There remain cases of less severe character, in which 
there is no foreign body in the eye: (1) the wound is in 
the dangerous region and complicated with traumatic cata¬ 
ract; (2) in the dangerous region without traumatic cata¬ 
ract; (3) the injury is entirely corneal, and therefore not 
in the dangerous zone, but the lens and iris are wounded; 
(4) there is wound of cornea and iris only, the lens escap¬ 
ing. In group (2) there will often be much difficulty in 
deciding what to do, it being presumed that the wounded 
eye shows no iritis or other signs of severe inflammation; 
some of the most difficult cases are those of wounds by sharp 
instruments close to the corneal border, with considerable 
adhesion of the iris, or in which there is evidence that the 
track lies between the lens and the ciliary processes, the 
lens not being wounded, and useful sight remaining. If 
the patient be seen within two or three weeks of the injury, 
and the sound eye show no irritation, we may safely watch 
the case for a few days. If decided sympathetic irritation 
be present, and do not yield after a few days’ treatment, 
excision is advisable, even though the lens of the wounded 
eye be uninjured. In regard to group (1), excision is, with- 


190 


CLINICAL DIVISION. 


out doubt, the safest course in all cases, whether or not the 
eye be causing sympathetic symptoms or be itself especially 
irritable; for there is little prospect of regaining useful 
vision in an eye with a ciliary wound and traumatic cata¬ 
ract. In group (3) excision is necessary if the wound be 
very large or irregular, and in some cases with small wound 
but persistent symptoms. In group (4) removal of the eye 
is very seldom justifiable, unless the iris having healed 
into the wound chronic inflammatory changes are present, 
or severe iritis and threatened panophthalmitis come on. 
The patient in all open cases must be warned, and must be 
seen every few days for many weeks. 

When sympathetic ophthalmitis has set in before the 
patient asks advice, the rule as to the excision of the ex¬ 
citing eye is different. 

The treatment of wounded eyes which are not excised is 
the same as for traumatic iritis and cataract, viz., atropine, 
rest, and local depletion. If seen before inflammation 
(iritis) has begun, ice is to be used. If the iris have pro¬ 
lapsed into the wound the protrusion should be drawn 
further out and a large piece of iris cut off, so that the 
ends when replaced by the curette may retract and remain 
quite free from the wound (see Iridectomy); this may be 
done as much as a week after the injury. Even when seen 
within an hour or two of the wound, the prolapse can 
seldom, in my experience, be either returned by manipula¬ 
tion or made to retract by eserine or atropine. 

It is sometimes important to determine whether an excised 
eye contain a foreign body. If nothing can be found in 
the blood or lymph, etc., by feeling with a probe, it is best 
to crush the soft parts, little by little, between finger and 
thumb, when the smallest particle will be felt. If a shot 
have entered and left the eye, the counter-opening may, if 
recent, be found from the inside, although no irregularity 
be noticeable outside the eyeball. 


CHAPTER XI. 


CATARACT. 

Cataract means opacity of the crystalline lens, and is 
due to changes in the structure and composition of the 
lens-fibres. The capsule is often thickened, but otherwise 
not much altered. The changes seldom occur throughout 
the whole lens at once, but begin first in a certain region— 
e. g ., the centre ( nucleus ) or the superficial layers (cortex), 
while in some forms of partial cataract the change never 
spreads beyond the part first affected. 

Senile changes in the lens. With advancing age the lens, 
which is from birth firmest at the centre, becomes harder, 
and acquires a very decided yellow color; its refractive 
power usually decreases, its surface reflects more light, and 
its substance becomes somewhat fluorescent. The result of 
all these changes is, that at an advanced age the lens is 
more easily visible than in early life, the pupil becoming 
grayish instead of being quite black. This grayness of the 
pupil may easily be mistaken for cataract, but ophthalmo¬ 
scopic examination shows that the lens is transparent, the 
fundus being seen without any appreciable haze. It has 
hitherto been supposed that the lens became smaller in old 
age, but the researches of Priestley Smith have lately shown 
that the lens continues to increase in all dimensions so long 
as it remains transparent. As a rule, however, cataractous 
lenses are undersized. 

The Etiology of Cataract. —In addition to the influence 
exerted by age in the production of cataract, there are 
other causes which occasionally act as factors. Thus,' 

( 191 ) 


192 


CLINICAL DIVISION. 


diabetes mellitus is responsible for about 1 per cent, of 
cases, this variety being bilateral and developing rapidly. 
Rachitis, nephritis, and some affections of the skin are 
credited with the production of the condition. Certain 
drugs, such as ergot and naphthalin, when introduced into 
the system are eminently causal in character. Heredity 
exerts a decided influence, and certain occupations, espe¬ 
cially glassblowing, favor its production. 

Local conditions within the eye not infrequently give rise 
to opacity of the crystalline lens, and the frequeut conges¬ 
tion of the choroid which has been noted in senile cata¬ 
racts has occasioned the opinion that cataract may be due 
to pathological changes in the choroid and ciliary bodies; 
others believe that cataracts develop as the result of errors 
of refraction, and seek to prevent further development of 
the opacity by careful and repeated correction of all forms 
of ametropia by glasses. 

The consistence of a cataract depends chiefly on the 
patient’s age. The wide physical differences between cata¬ 
racts depend less on variations in the cause, position, or 
character of the opacity than on the degree of natural 
hardness which is proper to the lens at the time when the 
opacity sets in. Below about thirty-five all cataracts are 
“ soft.” 


Forms of General Cataract. 

1. Nuclear cataract. The opacity begins in, and remains 
more dense at, the nucleus of the lens, thinning off gradu¬ 
ally in all directions toward the cortex (Fig. 74); the 
nucleus is not really opaque, but densely hazy. As the 
patients are generally old, nuclear cataract is usually senile 
and hard, and also often amber-colored or light brownish, 
like “ pea-soup ” fog. 

2. Cortical cataract. The change begins in the super- 


CATARACT. 


193 


ficial parts, and generally takes the form of sharply defined 
lines or streaks, or triangular patches, which point toward 
the axis of the lens, and whose shape is dependent on the 
arrangement of the lens-fibres. Fig. 75. They usually 
begin at the edge ( equator ) of the lens where they are hid¬ 
den by the iris, but when large enough they encroach on 
the pupil as whitish streaks or triangular patches. They 
affect both the anterior and posterior layers of the lens, 
and the intervening parts may be quite clear. Sooner or 
later the nucleus also becomes hazy (mixed cataract), and 
the whole lens eventually gets opaque. 

Some cases of the large class known as “senile” or 
“ hard ” cataract are nuclear from beginning to end —L e. y 
formed by gradual extension of diffused opacity from the 
centre to the surface; more commonly they are of the 
mixed variety. 

A few cataracts beginning at the nucleus, and many 
beginning at the cortex, are not senile in the sense of 
accompanying old age, and are, therefore, not hard. Some 
such are caused by diabetes, but in many it is impossible 
to say w 7 hy the lens should have become diseased. 1 Mey- 
hofer (1886), observing that opacities in the lens are dispro¬ 
portionately common in glassblowers, suggests that radiant 
heat may act as a direct cause of cataract. Many of them 
are known as “ soft ” cataracts when complete. They gen¬ 
erally form quickly, in a few months. A few are congen¬ 
ital. Whether nuclear or cortical, they are whiter and 
more uniform-looking than the slower cataracts of old age, 
and the cortex often has a sheen, like satin or mother-of- 
pearl, or looks flaky like spermaceti. 

In some cortical cataracts we find only a great number 



1 Lowered blood-supply from atheroma of the carotid has lately been sug¬ 
gested as a cause in some cases (Michel). Cataract does not seem to be often 
related to renal disease; but when renal albuminuria is present in a case of 
cataract, the prognosis for operation is decidedly less favorable than usual. 

13 


194 


CLINICAL DIVISION 


of very small dots or short streaks—dotted cortical cata¬ 
ract ; this form is generally stationary 7 or nearly so for 
years. Occasionally a single large, wedge-shaped opacity 
will form at some part of the cortex, and remain stationary 
and solitary for many years. Sometimes in suspected cata¬ 
ract, though no opaque striae are visible by focal illum¬ 
ination, one or more dark streaks, “striae of refraction” 
(Bowman), are seen with the mirror, altering as its incli¬ 
nation is varied, and having much the same optical effect 
as cracks in glass; these “ flaws ” should always be looked 
on as the beginning of cataract. 

Partial Cataract. 

Three forms need special notice. 

1. Lamellar (zonular) cataract is a peculiar and well- 
marked form in which the superficial laminse and the 
nucleus of the lens are clear, a layer or shell of opacity 
being present between them. Fig. 77. Examination shows 
a degenerated layer between the nucleus and cortex; in 
all the cases the nucleus has been been found degenerated. 
It is probable that the opacity is present at birth; it cer¬ 
tainly never forms late in life. The association of lamellar 
cataracts with rickets, and with a marked deformity of the 
permanent teeth, consisting of an abruptly limited defi¬ 
ciency of the enamel on the part furthest from the gums, 
is a very common one. The teeth affected are the first 
molars, canines, and incisors of the permanent set; the 
dental changes are quite different from those which are 
pathognomonic of inherited syphilis. The great majority 
of the subjects of lamellar cataract give a history of infan¬ 
tile convulsions. The cataract is probably due to some 
temporary interference with the nutrition of the lens in 
intra-uterine life, during the deposition of the affected 
layers. Mr. Hutchinson has collected many facts in favor 


CA TAR ACT. 


195 


of the belief that the dental defect is due to stomatitis 
interfering with the calcification of the enamel before the 
eruption of the teeth, and that mercury is the cause of the 
stomatitis. On this hypothesis the coincidence of the dental 
defect and of the cataract is due to mercury having been 
given for the convulsions from which these children suffer. 
It is reasonable to suppose, however, that the defect of the 
crystalline lens and of the enamel, both of them epiblastic 
structures, may be caused by some common influence. The 
size of the opaque lamella or shell, and therefore its depth 
from the surface of the lens, are subject to much variation, 
and it may be much smaller than is shown in the figure. 
The opacity is often stationary for years, perhaps for life, 
but cases are sometimes met with in which we cannot doubt, 
from the history, that the opacity has, without extending 
perceptibly, become more dense; instances of lamellar 
opacity spreading to the whole lens are, however, appar¬ 
ently very rare. 

2. Pyramidal cataract. A small, sharply-defined spot 
of chalky-white opacity is present in the middle of the 
pupil, at the anterior pole of the lens, looking as if it lay 
upon the capsule. When viewed sideways it seems to be 
superficially embedded in the lens, and also sometimes 

Fig. 72. 

0 

Pyramidal cataract seen from the front and in section. 

stands forward as a little nipple or pyramid, Fig. 72. It 
consists of the degenerated products of a localized inflam¬ 
mation just beneath the lens-capsule, with the addition of 
organized lymph derived from the iris and deposited on 
the front of the capsule, the capsule itself being puck- 




196 


CLINICAL DIVISION. 


ered and folded, Fig. 73. It is a stationary form, 
scarcely ever becoming general. 

Pyramidal cataract is the re¬ 
sult of central perforating ulcer¬ 
ation of the cornea in early life, 
and of this ophthalmia neon¬ 
atorum is nearly always the 
cause ; it is, therefore, often asso¬ 
ciated with corneal nebula. The 
contact between the exposed part 
of the lens-capsule and the in¬ 
flamed cornea,which occurs when 
the aqueous has escaped through 
the hole in the ulcer, appears to 
set up the localized subscapular 
inflammation. Iritis in very 
early life may also cause similar 
opacities at the points of adhe¬ 
sion between the iris and lens. 

The term anterior polar cata¬ 
ract is applied both to the form 
just described and to certain rare 
cases in which general cataract 
begins at this part of the lens. 

3. Cataract, which afterward becomes general, may 
begin as a thin layer at the middle of the hinder surface 
of the lens— posterior polar cataract. Fig. 76. There are 
many varieties, but in general the pole itself shows the 
most change, the opacity radiating outward from it in more 
or less regular spokes. The color appears grayish, yellow¬ 
ish, or even brown, because seen through the whole thick¬ 
ness of the lens. Sometimes the opacity is due to formations 
adherent to the back of the capsule— i. e., in front of the 
vitreous; but this can seldom be proved during life. Cata¬ 
ract beginning at the posterior pole is often a sign of dis- 


Fig. 73. 



Magnified section of an anterior 
polar cataract of eleven years’ for¬ 
mation. A complete layer of hy¬ 
aline capsule lined by cells is 
shown behind the opacity, and a 
hyaline layer in front of it. (After 
Treacher Collins.) 







CATARACT. 


197 


ease of the vitreous depending on choroidal mischief; it is 
common in the later stages of retinitis pigmentosa and 
severe choroiditis, and in high degrees of myopia with dis¬ 
ease of the vitreous. The prognosis, therefore, should 
always, be guarded in a case of cataract where the prin¬ 
cipal part of the opacity is in this position. 

When a cataract forms without known connection with 
other disease of the eye, it is said to be primary. The term 
complicate cataract is used when it is the consequence of 
some local disease, such as severe iridocyclitis, glaucoma, 
detachment of the retina, or the growth of a tumor in the 
eye. Primary cataract is symmetrical in most cases, but 
an interval, which may extend over several years, usually 
separates its onset in the two eyes. Complicate cataract, 
of course, may or may not be symmetrical. Secondary 
cataract is a term used to designate the remnant of lens 
and capsular matter which often follows the removal of a 
primary cataract. 

Diagnosis of Cataract. The subjective symptoms of 
cataract depend solely on the obstruction and distortion of 
the entering light by the opacities. Objectively, cataract 
is shown in advanced cases by the white or gray condition 
of the pupil at the plane of the iris; in earlier stages by 
whitish opacity in the lens when examined by focal light 
(p. 58), and by corresponding dark portions, lines, spots, 
or patches in the red pupil when examined by the oph¬ 
thalmoscope mirror. 

Both subjective and objective symptoms differ with the 
position and quantity of the opacity. When the whole 
lens is opaque the pupil is uniformly whitish ; the opacity 
lies almost on a level with the iris, no space intervening, 
and consequently, on examining by focal light we find that 
the iris casts no shadow on the opacity ; the brightest light 
from the mirror will not penetrate the lens in quantity 
enough to illuminate the choroid, and hence no red reflex 


198 


CLINICAL DLVISION. 


will be obtained. Such a cataract is said to be mature or 
“ ripe,” and the affected eye will be in ordinary terms 
“ blind.” If both cataracts be equally advanced, the 
patient will be unable to see any objects; but he will dis¬ 
tinguish quite easily between light and shade when the eye 
is alternately covered and uncovered in ordinary daylight, 
good perception of light, p. 1 ., and will tell correctly the 
position of a candle flame—good projection. The pupils 
should be active to light and not dilated, the tension 
normal. 

In a case of incipient cataract the patient complains of 
gradual failure of sight, and we find the acuteness of 
vision impaired, probably more in one eye than in the 
other, and more for distant than for near objects. In the 
earliest stages of senile cataract some degree of myopia 
may be developed (Chapter XX.), or, owing to irregular 
refraction by the lens, the patient may see with each eye 
two or more images of any object close together —polyopia 
uniocular is. If he can still read moderate type, the glasses 
appropriate for his age and refraction, though giving some 
help, do not remove the defect. If, as is usual, he be pres¬ 
byopic, he will be likely to choose over-strong spectacles, 
and to place objects too close to his eyes, so as to obtain 
larger retinal images, and thus compensate for want of 
clearness. In nuclear cataract, as the axial rays of light 
are most obstructed, sight is often better when the pupil is 
rather large, and such patients tell us that they see better 
in a dull light, or with the back to the window, or when 
shading the eyes with the hand. In the cortical and more 
diffused forms this symptom is less marked. 

On examining by focal light, the pupil having been 
dilated, an immature nuclear cataract appears as a yellow¬ 
ish, rather deeply-seated haze, upon which a shadow is cast 
by the iris on the side from which the light comes. 
Fig. 74, 3. On now using the mirror this same opacity 


CATARACT. 


199 


appears as a dull blur in the area of the red pupil, darkest 
at the centre, and gradually thinning off on all sides, so 
that, at the margin of the pupil, the full red choroidal 


Fig. 74. 


1 2 3 



Nuclear cataract. 1. Section of lens : opacity densest at centre. 2. Opacity 
as seen by transmitted light (ophthalmoscope mirror) with dilated pupil. 
3. Opacity as seen by reflected light (focal illumination). The pupil is sup¬ 
posed to be dilated by atropine. 


reflex may still be present; the details of the fundus, if 
still visible, are obscured by the hazy lens, the haze being 
thickest when we look through the centre of the pupil. 
Fig. 74, 2. If the opacity be dense and large, a faint dull 
redness will be visible, and that only at the border of the 
pupil. 

Cortical opacities, if small and confined to the equator 
(or edge) of the lens, do not interfere with sight; they are 
easily detected with a dilated pupil by throwing light very 
obliquely behind the iris. When large and encroaching 
on the pupil they are visible in ordinary daylight. They 
occur in the form of dots, streaks, or wedges; seen by focal 




Fig. 75. 


Cortical cataract. References as in preceding figure. 


light they are whitish or grayish, and more or less sharply 
defined according as they are in the anterior or posterior 
layers. Fig. 75, 3. With the mirror they appear black 
or grayish, and of rather smaller size, Fig. 75, 2; and if 





200 


CLINICAL DIVISION. 


the intervening substance be clear, the details of the fundus 
can be seen sharply between the bars of opacity. Some 
forms of cataract begin with innumerable minute dots in 
the cortical layer. 

Posterior polar opacities are seldom visible without care¬ 
ful focal illumination, when we find a patchy or stellate 
figure very deeply seated in the axis of the lens, Fig. 76, 3 ; 

0 

if large it looks concave like the bottom of a shallow cup. 
With the mirror it is seen as a dark star, Fig. 76, 2, or 
network, or irregular patch, but smaller than when seen 
by focal light. 

The diagnosis of lamellar cataract is easy if its nature 
be understood, but by beginners it is often diagnosed as 
“ nuclear.” The patients are generally children or young 
adults; they complain of “near sight” rather than of 
“ cataract;” for the opacity is not usually very dense, and 
whether the refraction of their eyes be really myopic or 
not, they, like other cataractous patients, compensate for 
dull retinal images by holding the object nearer, and so 
increasing the size of the images. The acuteness of vision 
is always defective, and cannot be fully remedied by any 
glasses. They often see rather better when the pupils are 
dilated, either by shading the eyes or by means of atropine ; 
in the latter case convex glasses (+ 4 or -f 4.5 D.) are 
necessary for reading. The pupil presents a deeply-seated, 
slight grayness, Fig. 77, 4, and when dilated with atropine 
the outline of the shell of opacity is exposed within it. 
This opacity is sharply defined, circular and whitish by 



Posterior polar cataract. References as before. 



CATARACT. 


201 


focal light, interspersed in many cases with white specks, 
which at its equator appear as little projections, Fig. 77, 3. 
By focal illumination we easily make out that the opacity 
consists of two distinct layers, that there is a layer of clear 
lens-substance, cortex, in front of the anterior layer, and 
that the margin, equator, of the lens is clear. By the 
mirror the opacity appears as a disk of nearly uniform 
grayish or dark color, sometimes with projections, or 
darker dots, and surrounded by a zone of bright-red 
reflection from the fundus corresponding to the clear mar- 


Fig. 77. 

12 3 



Lamellar cataract. 1, 2, 3, as before. 4 shows slight grayness of the undilated 
pupil owing to the layers of opacity being deeply seated. 


gin of the lens. Fig. 77, 2. The opacity often appears 
rather denser at its boundary, a sort of ring being formed 
there; and in some cases quite large spicules or patches 
project from the part. Not only does the size of the opaque 
lamella, and, therefore, its depth from the surface of the 
lens, differ greatly in different cases, but its thickness or 
degree of opacity varies also. The disease is nearly always 
symmetrical in the two eyes. Occasionally there are two 
shells of opacity, one within the other, separated by a cer¬ 
tain amount of clear lens-substance. 

The lens may be cataractous at birth —congenital cata¬ 
ract. This form, of which there are several varieties, is 





202 


CLINICAL DIVISION. 


nearly always symmetrical, and generally involves the 
whole lens. Often the development of the eyeball is de¬ 
fective, and though there are no synechise, the iris may act 
badly to atropine. Cases are seen from time to time in 
which juvenile or perhaps congenital cataract appears in 
many members of a family, even in several generations. 

Prognosis of Cataract, a. Course. Although opaci¬ 
ties in the lens never clear up, 1 they advance with very 
varying rapidity in different cases. As a rough rule, the 
progress of a general cataract is rapid in proportion to the 
youth of the patient. Cataracts in old people commonly 
take from one to three years in reaching maturity—some¬ 
times much longer; there are cases of nuclear senile cata¬ 
ract where the opacity never spreads to the cortex, and 
the cataract never becomes “ complete,” though it may 
become dry and “ripe” for operation. If the lens be 
allowed to remain very long after it is opaque, further 
degenerative changes generally occur; it may become 
harder and smaller, calcareous and fatty granules being 
formed in it; or the cortex may liquefy while the nucleus 
remains hard (Morgagnian cataract ). A congenital cataract 
may undergo absorption and shrink to a thin, firm, mem¬ 
branous disk. Soft cataract in young adults, from what¬ 
ever cause, is generally complete in a few months. 

b. Sight. The prognosis after operation is good when 
there is no other disease of the eye, and when the patient 
(although advanced in years) is in fair general health. It 
is not so good in diabetes, nor when the patient is in 
obviously bad health, the eyes being then less tolerant of 
operation. In the lamellar and other congenital varieties 
it must be guarded, for the eyes are often defective in other 
respects, and sometimes very intolerant of operation; the 
intellect, too, is sometimes defective, rendering the patient 


1 Except sometimes in diabetes. Chapter XXIII. 


CATARACT. 


203 


less able to make proper use of his eyes. In traumatic 
cataract, of course, everything depends on the details of 
the injury, but, as a rule, the younger the patient the better 
the prospect of a quiet and uncomplicated absorption of 
the lens. 

In every case of immature cataract, the vitreous and 
fundus should be carefully examined by the ophthalmo¬ 
scope, and the refraction ascertained. The presence of 
high myopia is unfavorable, and the same is true of opaci¬ 
ties in the vitreous, indicating, as they usually do, that it 
is fluid. Any disease of the choroid or retina will, of 
course, be prejudicial in proportion to its position and ex¬ 
tent. In every case before deciding to operate, the state 
of the conjunctiva and lachrymal passages, the tension of 
the eye, and the size and mobility of the pupils to light, 
are to be carefully noted. 

Treatment. In the early stages of senile and nuclear 
cataract, sight is improved by keeping the pupil moderately 
dilated with a weak mydriatic solution, one-eighth of a 
grain of atropine to the ounce, used about three times a 
week. Dark glasses, by allowing some dilatation of the 
pupil, also assist. Stenopaic glasses are sometimes useful. 
With these exceptions, nothing except operative treatment 
is of any use. The management of lamellar cataract 
requires separate description. 

Operations for the removal of cataract are of three kinds : 
1. Extraction of the lens entire through a large wound in the 
cornea, or at the sclero-corneal junction, the lens-capsule 
remaining behind. By a few operators the lens is removed 
entire in its capsule. 2. For soft cataracts, gradual absorp¬ 
tion, by the agency of the aqueous humor admitted through 
needle punctures in the capsule, just as after accidental 
traumatic cataract, needle operations, solution, discission. 
The operation needs repetition two or three times, at inter¬ 
vals of a few T weeks, and the whole process therefore occupies 


204 


CLINICAL DIVISION. 


three or four months. 3. For soft cataracts, removal by 
curette or suction syringe, introduced into the anterior cham¬ 
ber through a small wound near the margin of the cornea, 
the whole lens having been freely broken up by a discission 
operation a few days previously. Chapter XXII. The 
use of the suction syringe is attended by risk of irido¬ 
cyclitis ; evacuation of the swollen lens along the groove 
of a curette just passed into the wound is much safer, and 
is almost equally effectual. The great advantage of this 
method over that of gradual absorption is the saving of 
time, almost the whole lens being removed at one sitting. 

Extraction is necessary for cataracts after about the age 
of forty. The lens from this age onward is so firm that its 
absorption after discission occupies a much longer time 
than in childhood and youth; moreover, as already stated, 
the swelling of the lens after wound of the capsule is less 
easily borne as age advances, and hence solution operations 
become not only slower but attended by more danger. 
Indeed, though suction and solution operations are appli¬ 
cable up to about the age of thirty-five, extraction is often 
practised in preference at a much earlier age. 

If one eye present a complete cataract while the sight of 
the other is perfect, or at least serviceable, removal of the 
cataract will confer little immediate benefit on the patient. 
Indeed, if one eye be still fairly good, the patient will often 
be dissatisfied by finding his operated eye less useful than 
he expected, perhaps even not so useful as the other. In 
senile cataract, therefore, it is usually best not to operate 
so long as the lens of the other eye remains nearly clear; 
but as soon as it becomes sufficiently affected to interfere 
seriously with vision, extraction of the cataract from the 
first eye is advisable, provided that the patient has a fair 
prospect of life. The cataract in the first eye may be over¬ 
ripe and less favorable for operation if it be left until the 
second eye is quite ready. The removal of a single cata- 


CATARACT. 


205 


ract in young persons is often expedient on account of 
appearance. In all cases of single cataract it must be 
explained that after the operation the two eyes will not 
work together on account of the extreme difference of 
refraction. See Anisometropia. 

Even when both cataracts are mature at the same time, 
it is safer to remove only one at once, because the after- 
treatment is more easily carried out upon one eye than 
both, and because after the double operation any untoward 
result in one eye adds to the difficulty of managing its 
fellow; while a bad result after single extraction enables 
us to take especial precautions, or to modify the operation 
for the second eye. Even if the patient be so old or feeble 
that the second eye may never come to operation, we shall 
consult his interests better by endeavoring to give him one 
good eye than by risking a bad result in attempting to 
restore both at the same time. 

Cataract occurring after the age of forty can seldom be 
safely extracted until it is complete or “ ripe.” The trans¬ 
parent portions of an immature cataract cannot be com¬ 
pletely removed, partly because they are sticky, partly 
because they cannot be seen; and, remaining behind in 
the eye, they act as irritants, and often set up iritis. 
Incomplete juvenile cataract— e.g., lamellar cataract, may 
be safely ripened by tearing the capsule with a needle (see 
Discission and Suction); but hard cataract cannot be so 
treated because the lens is too hard to absorb the aqueous 
well, and the senile eye is intolerant of injury to the lens. 

Several years ago Professor Forster, of Breslau, proposed a 
plan for hastening the completion of very slow senile cataracts ; 
immediately after the iridectomy he bruises the lens by rubbing 
the cornea firmly over the pupil with a cataract spoon or other 
smooth instrument; the capsule is not ruptured, but the lens- 
fibres are broken up or so changed that they often become 
opaque a few weeks or months after. Others adopt the safer 


206 


CLINICAL DIVISION. 


plan of bruising the lens directly by means of a small bulbous 
spatula passed through the corneal wound. These methods 
are very uncertain, sometimes having no effect, but the latter 
modification may be employed without risk in suitable cases. 

The principal causes of failure after extraction of cataract 
are: 

1. Hemorrhage between the choroid and sclerotic coming 
on, usually with severe pain, immediately after the opera¬ 
tion. The blood fills the eyeball, and often oozes from the 
wound and soaks through the bandage. 

2. Suppuration, beginning in the corneal wound, spread¬ 
ing to the iris and vitreous, and in many to the entire cor¬ 
nea, and ending in total loss of the eye. It occasionally 
takes a less rapid course, and stops short of a fatal result. 
The alarm is given in from twelve hours to about three 
days after operation by the occurrence of pain, inflamma¬ 
tory oedema of the lids, particularly the free border of the 
upper lid, and the appearance of some muco-purulent dis¬ 
charge. On raising the lid the eye is found to be greatly con¬ 
gested, its conjunctiva cedematous, the edges of the wound 
yellowish, and the cornea steamy and hazy. In very rapid 
cases the pupil, especially near to the wound, will already 
be occupied by lymph. Suppuration is probably always 
caused by infection, though the source of the mischief of 
course, often remains hidden. Chronic dacryocystitis is a 
very dangerous concomitant of cataract operations, the pus 
escaping through the puncta and infecting the wound. 
Suppuration is more probable if the wound lie in clear 
corneal tissue than if it be partly scleral, and if the patient 
be in bad or feeble health. 

The use of hot fomentations for an hour three or four 
times a day, leeches if there be much pain, and internally 
a purge, followed by quinine and ammonia, and wine or 
brandy if the patient be feeble, should be at once resorted to. 
As to other measures opinions differ. From what I have 


CATARACT. 


207 


seen of my own cases and those of others, I am, at present, 
inclined to agree with Horner and those who direct most 
attention to the vigorous antiseptic treatment of the wound 
itself; I have found that the actual (galvano-) cautery ap¬ 
plied deeply along the whole length of the wound, or wash¬ 
ing out the wound, and the anterior chamber if necessary, 
with freshly prepared chlorine water, are more successful 
than any other measures ; they should be assisted, however, 
by hot fomentations and the use of iodoform or of weak 
lotions of chloride of zinc or bichloride of mercury, and by 
leaving the eye open. 1 But only in the cases of moderate 
rapidity and intensity can we hope, even partly, to arrest 
the disease, for the great majority of these cases go on to 
suppurative panophthalmitis, or to severe plastic irido¬ 
cyclitis with opacity of cornea and shrinking of the eyeball. 

3. Iritis may set in between about the fourth and tenth 
days. Here also pain, oedema of the eyelids, and chemosis 
are the earliest symptoms. There is lachrymation, but no 
muco-purulent discharge, and the cornea and wound usu¬ 
ally remain clear. The iris is discolored (unless it happen 
to be naturally greenish-brown), and the pupil dilates badly 
with atropine. Whenever, in a case presenting such symp¬ 
toms, a good examination is rendered difficult on account 
of the photophobia, iritis should be suspected. If the early 
symptoms are severe, a few leeches to the temple are very 
useful. Atropine and warmth are the best local measures. 
If atropine irritate, scopoline, daturine, or duboisine should 
be tried (F. 34, 36, 37). 

This inflammation is plastic, ending in the formation of 
more or less dense membrane in the pupil. Such mem¬ 
brane, by contracitng and drawing the iris with it toward 
the operation scar, often displaces the pupil. Fig. 158 
shows this in an extreme degree. The membrane is formed 

i Mr. C. T. Collins, the house-surgeon at Moorflelds, suggested to me the 
last-named measure. 


208 


CLINICAL DIVISION. 


partly by exudation from the iris and ciliary processes, 
iritis, cyclitis, partly by the lens-capsule and its proliferated 
endothelial cells, capsulitis. Mixed forms of chronic kera¬ 
titis and iritis sometimes occur, the corneal haze spreading 
from the wound in the form of long lines or stripes. Iritis 
of obstinately plastic type is liable to occur after extraction 
of cataract in diabetes. 

4. The iris may beocome incarcerated in or prolapse 
through the wound at the operation, or a few days after¬ 
ward by the reopening of a weakly united wound. When 
iridectomy has been done the prolapse appears as a little 
dark bulging at one or both ends of the wound, and often 
causes prolonged irritability without actual iritis. The best 
treatment is to draw the protruding part further out, and 
to cut it off as freely as possible, as in accidental wounds. 
The occurrence of prolapse is a reason for keeping the eye 
tied up longer. The capsule also may be incarcerated in 
or adherent to the wound after extraction, suction, or 
curette (simple linear) extraction. After-operations are 
needed if the pupil be much obstructed by capsular opaci¬ 
ties or by the results of iritis; but nothing should be done 
until active symptoms have subsided and the eye been 
quiet for some weeks. 

Sight after the removal of cataract. In accounting for 
the state of the sight we have to remember that the acute¬ 
ness of sight naturally decreases in old age; that slight 
iritis, producing a little filmy opacity in the pupil, is com¬ 
mon after extraction ; and that some eyes, with good sight, 
remain irritable for long after the operation, and therefore 
cannot be much used. Thus, putting aside the graver 
complications, we find that, even of the eyes which do best, 
only a moderate proportion reach normal acuteness of 
vision. Cases are considered good when the patient can 
with his glasses read anything between Nos. 1 and 14 Jaeger 
and r 6 g- Snellen ; but a much less satisfactory result than 


CATARACT. 


209 


this is very useful. About 5 per cent, of the eyes operated 
upon are lost from various causes. The eye is rendered 
extremely hypermetropic by removal of the lens, and fre¬ 
quently there is a good deal of astigmatism due to flatten¬ 
ing of that meridian of the cornea which is at a right angle 
with the operation wound. Strong convex glasses are neces¬ 
sary for clear vision; these should seldom be allowed until 
three months after the operation, and at first they should 
not be continuously worn. Two pairs are needed: one 
makes the eye emmetropic, and gives clear distant vision 
(+ or 11 F>.); the other (about -f-15 D.) is for reading, 
sewing, etc., at about 10" (25 cm.) as during strong accom¬ 
modation. When there is astigmatism it should usually be 
corrected. As all accommodation is lost, the patient has 
no range of distinct vision. 

Lamellar cataract. If the patient can see enough to get 
on fairly well at school, or in his occupation, it may be best 
not to operate; but when, as is the rule, the opacity is 
dense enough to interfere seriously with his prospects, 
something must be done. The choice lies between artifi¬ 
cial pupil when the clear margin is wide and quite free 
from spicules, and solution or extraction when it is narrow, 
or when large spicules of opacity project into it from the 
opaque lamella. Fig. 77. My own experience is decidedly 
in favor of removing the lens in the majority of cases. A 
very good rule is to operate on only one eye at a time, thus 
allowing the choice of a different operation on its fellow. 

When a cataractous eye is absolutely blind some more 
deeply-seated disease must be present, and no operation 
should be undertaken; and when projection and p. 1. are 
bad great caution is needed. 

Cataract following injury. Severe blows on the eye may 
be followed by opacity of the lens, the capsule and often 
the suspensory ligament being no doubt torn in some part— 
concussion cataract. Lawford has shown that rupture of the 

14 


210 


CLINICAL DIVISION. 


posterior capsule may occur from a blow, while the anterior 
capsule remains intact (Ophth. Rev., vi. 281). Such a cata¬ 
ract may remain incomplete and stationary for an indefi¬ 
nite period, but often it becomes complete. Traumatic 
cataract proper is the result of wound of the lens-capsule; 
the aqueous passing through the aperture is imbibed by the 
lens-fibres, which swell up, become opaque, and finally dis¬ 
integrate and are absorbed. The opacity begins within a 
few hours of the wound ; it progresses quickly in proportion 
as the wound is large and the patient young ; but both the 
symptoms and consequences are often more severe in old 
persons. A free wound of the capsule, followed by rapid 
swelling of the whole lens, may give rise, especially after 
middle life, to severe glaucomatous symptoms and iritis. 
In from three to six months a wounded lens will generally 
be absorbed, and nothing but some chalky-looking detritus 
remain in connection with the capsule. A very fine punc¬ 
ture of the lens is occasionally followed by nothing more 
than a small patch or narrow track of opacity, or by very 
slowly advancing general haze. Occasionally partial opaci¬ 
ties of the lens caused by injury clear up entirely. The 
objects of treatment are to prevent iritis by atropine, and by 
leeching if there be pain; it is usually safest to leave the 
wounded lens to become absorbed, but we must be prepared 
to extract it by linear operation or suction at any time 
should glaucoma, iritis, or severe irritation arise. A con¬ 
cussion cataract, however, is seldom completely absorbed; 
the lens shrinks, and may then become loosened and fall 
either into the vitreous or aqueous chamber. I believe, 
therefore, that it is usually best to remove by operation a 
cataract following a blow. It will often be observed in 
both these forms of cataract that the opacity appears at 
the posterior surface of the lens quite early, whether the 
wound have penetrated deeply or not. 

Dislocation of the lens in its capsule is usually caused 


CATARACT. 


211 


by a blow on the eye, but may be spontaneous; it is, as a 
rule, only partial. The iris is often tremulous where its 
support is lost, and bulged forward at some other part 
where the lens rests against it; by focal light, or by the 
ophthalmoscope, the free edge of the lens can be seen as a 
curved line passing across the pupil, more easily if the 
pupil be dilated. More rarely the dislocation is complete, 
either into the vitreous or into the anterior chamber. A 
full-sized lens dislocated into the anterior chamber causes 
acute glaucoma. Glaucoma, acute or chronic, may also 


Fig. 78. 



Dislocation of lens. (Jaeger.) 


follow at any time after a dislocation, either partial or 
complete, into the vitreous. Dislocated lenses often be¬ 
come opaque and shrunken, and then either remain loose 
or become adherent, and in either event are likely, sooner 
or later, to set up irritation and pain. Such a lens may 
sometimes be made to pass at will through the pupil by 
altering the position of the head. The edge of a trans¬ 
parent lens in the vitreous appears, by the mirror, as a 
dark line; when in the anterior chamber it appears as a 
bright line, by focal illumination. If the lens be dislocated 
into the anterior chamber it is necessary to extract it; a 




212 


CLINICAL DIVISION. 


myotic should first be used to prevent backward displace¬ 
ment of the lens into the vitreous. If the lens be floating 
freely in the vitreous it is impossible to remove it; if it be 
only partially dislocated it may be removed by the hook 
or spoon. Congenital dislocation, ectopia lentis, is due to 
defective development of the suspensory ligament; it is 
often accompanied by other defects of development, such 
as coloboma. 

For dislocation of lens beneath conjunctiva in rupture 
of the eye, see p. 180. 


CHAPTER XII. 


DISEASES OF THE CHOROID. 

The choroid is, next to the ciliary processes, the most 
vascular part of the eyeball, and from it the outer layers 
of the retina certainly, and the vitreous humor probably, 
are mainly nourished. Inflammatory and degenerative 
changes often occur, some of them entirely local, as in 
myopia; others symptomatic or constitutional or of gener¬ 
alized disease, such as syphilis and tuberculosis. Choro¬ 
iditis, unlike inflammations of its continuations, the ciliary 
body and iris, is seldom shown by external congestion or 
severe pain; and as none of its symptoms are characteris¬ 
tic, the diagnosis rests chiefly on ophthalmoscopic evidence. 

Blemishes or scars, permanent and easily seen, nearly 
always follow disease of the choroid, and such spots and 
patches are often as useful for diagnosis as cicatrices on 
the skin, and deserve as careful study. The retina lying 
over an inflamed choroid often takes on active changes, or 
becomes atrophied afterward; but in other cases, marked 
by equally severe changes, the retina is uninjured. Indeed, 
there is sometimes difficulty in deciding which of these two 
structures was first affected, especially as changes in the 
pigment epithelium, which is really part of the retina, are 
as often the result of deep-seated retinitis, or retinal hem¬ 
orrhage, as of superficial choroiditis. Patches of accumu¬ 
lated pigment, though usually indicating spots of former 
choroiditis, are sometimes the result of bleeding, either 
from retinal or choroidal vessels, and their correct inter¬ 
pretation may therefore be difficult. 


( 213 ) 


CLINICAL DIVISION. 


214 

Appearances in health. The choroid is composed chiefly 
of bloodvessels and of cells containing dark-brown pigment. 
The quantity of pigment varies in different eyes, and to some 
degree in different parts of the same eye; it is scanty in 
early childhood, and in persons of fair complexion; more 
abundant in persons with dark or red hair, brown irides, 
or freckled skin ; more plentiful in the region of the yellow 
spot than elsewhere. In old age the pigment epithelium 
becomes paler. When examining the choroid we need to 
think of four parts: (1) the retinal pigmented epithelium, 
which is for ophthalmoscopic purposes choroidal, seen in 
the erect image as a fine dark stippling; (2) the capillary 
layer, chorio-capillaris, just beneath the epithelium, form¬ 
ing a very close meshwork, the separate vessels of which 
are not visible in life; (3) the larger bloodvessels, often 
easily visible; (4) the pigmented connective-tissue cells of 
the choroid proper, which lie between the larger vessels. 

In the majority of eyes these four structures are so toned 
as to give a nearly uniform, full red color by the ophthal¬ 
moscope, blood-color predominating. In very dark races 
the pigment is so excessive that the fundus has an uniform 
slaty color. In very fair persons, and young children, the 
deep pigment (4) is so scanty that the large vessels are sepa¬ 
rated by spaces of lighter color than themselves. Fig. 37. 
In dark persons these same spaces are of a deeper hue than 
the vessels, the latter appearing like light streams separated 
by dark islands. See upper part of Fig. 88. Near to the 
disk and y. s. the vessels are extremely abundant and very 
tortuous, the interspaces being small and irregular; but 
toward and in front of the equator the veins take a nearly 
straight course, converging toward the vence vorticosce, and 
the islands are larger and elongated. The veins are much 
more numerous and larger than the arteries, Fig. 80, but 
wo cannot often distinguish between them in life. The 
vessels of the choroid, unlike those of the retina, present no 


DISEASES OF THE CHOROID. 


215 


light streak along the centre. The pigment epithelium 
and the capillary layer tone down the above contrasts, and 
so in old age, when the epithelial pigment is bleached, or 
if the capillary layer be atrophied after superficial choroid¬ 
itis, Fig. 81, a and b, the above distinctions become very 
marked. 

A vertical section of naturally injected human choroid 
is shown in Fig. 79 ; the uppermost dark line (1) is the 
pigment epithelium; next are seen the capillary vessels 

(2) , cut across; then the more deeply-seated large vessels 

(3) , and the deep layer of stellate pigment-cells of the 
choroid proper (4). Fig. 80 is from an artificially injected 
human choroid seen from the inner surface. The shaded 


Fig. 79. 



Human choroid, vertical section. Naturally injected. X 20. 

portion is intended to represent the general effect produced 
by all the vessels and the pigment epithelium. The lowest 
part shows the large vessels with their elongated interspaces, 
as may be seen in a case where the pigment epithelium and 
chorio-capillaris are atrophied, Fig. 81, b; in a dark eye 
the interspaces in Fig. 80 would be darker than the vessels. 
The middle part shows the capillaries without the pigment 
epithelium. Both figures are magnified about four times as 
much as the image in the indirect ophthalmoscopic exam¬ 
ination. 

Ophthalmoscopic Signs of Disease of the Choroid. 

The changes usually met with are indicative of atrophy. 
This may be partial or complete; primary, or following 
inflammation or hemorrhage; in circumscribed spots and 
patches, or in large and less abruptly bounded areas. 




216 


CLINICAL DIVISION. 


Secondary changes are often present in the correspond¬ 
ing parts of the retina. The chief signs of atrophy of the 
choroid are: (1) the substitution of a paler color, varying 

Fig. so. 



Vessels of human choroid artificially injected. Arteries cross-shaded. 
Capillaries too dark and rather too small. The uppermost shaded part is 
meant to represent the effect of the pigment epithelium. X 20. 


from pale red to yellowish-white, for the full red of health, 
the subjacent white sclerotic being more or less visible 
where the atrophic changes have occurred; (2) black pig- 





























DISEASES OF THE CHOROID. 


217 


ment in spots, patches, or rings, and in varying quantity, 
upon or around the pale patches. These pigmentations 
result, first, from disturbance and heaping together of the 
normal pigment; second, from increase in its quantity; 
third, from blood-coloring matter left after extravasations. 
Patches of primary atrophy— e.cj., in myopia—are never 
much pigmented unless bleeding has taken place. The 
amount of pigmentation in atrophy following choroiditis is 
closely related to that of the healthy choroid— i. e., to the 
complexion of the person. 


Fig. 81 . 



Atrophy after syphilitic choroiditis, showing various degrees of wasting 
(Hutchinson), a. Atrophy of pigment epithelium, b. Atrophy of epithe¬ 
lium and chorio-capillaris; the large vessels exposed, c. Spots of complete 
atrophy, many with pigment accumulation. 


Pigment at the fundus may lie in the retina as well as 
in or on the choroid, and this is true whatever may have 
been its origin, for in choroiditis with secondary retinitis 
the choroidal pigment often passes forward into the retina. 
When a spot of pigment is distinctly seen to cover a reti¬ 
nal vessel that spot must be not only in, but very near 



































































































218 


CLINICAL DIVISION. 


the anterior (inner) surface of, the retina; and when the 
pigment has a linear, mossy or lace-like pattern, Fig. 91, 
it is always in the retina; these are the only conclusive 
tests of its position. 

It is important, and usually easy, to distinguish between 
partial and complete atrophy of the choroid. In super¬ 
ficial atrophy , affecting the pigment epithelium and capil¬ 
lary layer, the large vessels are peculiarly distinct. Fig. 
81, a and h. Such “ capillary ” or “ epithelial ” choriditis 
often covers a large surface, the boundaries of which are 
sometimes well-defined, sinuous and map-like, but are as 
often ill-marked ; in the latter case we must carefully com¬ 
pare different parts of the fundus, and also make allowance 
for the patient’s age and complexion. Complete atrophy 
is shown by the presence of patches of white or yellowish- 
white color of all possible variations in size, with sharply- 
cut, circular or undulating borders, and with or without 
pigment accumulations. Fig. 81, c. The retinal vessels 
pass unobscurbed over patches of atrophied choroid, prov¬ 
ing that the appearance is caused by some change deeper 
than the surface of the retina. 

If the patient comes with recent choroiditis we also often 
see patches of palish color, but they are less sharply 
bounded, and frequently of a grayer or whiter (less yellow) 
color than patches of atrophy ; moreover the edge of such 
a patch is softened, the texture of the choroid being dimly 
visible there, because only partly veiled by exudation. If 
the overlying retina be unaffected its vessels are clearly 
seen over the diseased part, but if the retina itself is hazy 
or opaque the exact seat of the exudation often cannot be 
at once decided; and this difficulty is often increased by 
the hazy state of the vitreous. 

Syphilitic choroiditis begins in, and is often confined to, 
the inner (capillary) layer of the choroid, Fig. 82, and 
hence it often affects the retina. In miliary tuberculosis 


DISEASES OF THE CHOROID. 


219 


of the choroid the overlying retina is clear, and the growth 
is, for the most part, deeply seated. Fig. 83. After very 
severe choroiditis, or extensive hemorrhage, absorption is 
often incomplete; we find then, in addition to atrophy, 
gray or white patches, or lines, which, in pattern and 


Fig. 82. 



Minute exudations into inner layer of choroid in syphilitic choroiditis. 
Pigment epithelium adherent over the exudations, but elsewhere has been 
washed off. Ch. Choroid. Scl. Sclerotic. X 20. 

appearance, remind us of keloid scars in the skin, or of 
patches and lines of old thickening on serous membranes. 

Very characteristic changes are seen after rupture of the 
choroid from sudden stretching caused by blows on the front 
of the eye. These ruptures, always situated in the central 
region, occur in the form of long tapering lines of atrophy, 
usually curved toward the disk, and sometimes branched, 


Fig. 83. 



Section of miliary tubercle. Inner layers of choroid comparatively unaf¬ 
fected. The lighter shading, surrounding an artery in the deepest part of the 
tubercle, represents the oldest part, which is caseating ; an artery is seen cut 
across in this part of the tubercle. X 20. 

Fig. 84; their borders are often pigmented. If seen soon 
after the blow, the rent is more or less hidden by blood, 
and the retina over it is hazy. 

The pathological condition known as “ colloid disease” 
of the choroid consists in the growth of very small hyaline 















220 


CLINICAL DIVISION. 


nodules, soft at first, afterward becoming hard like glass, 
from the thin lamina elastica which lies between the pig¬ 
ment epithelium and chorio-capillaris. It is common in 

Fig. 84. 



Rupture of choroid. (Wecker) 

eyes excised for old inflammatory mischief, and in partial 
atrophy after choroiditis. Fig. 85. But little is known 
of its ophthalmoscopic equivalent, or its clinical characters. 


Fig. 85. 



Partial atrophy after syphilitic choroiditis. Minute growths from inner sur¬ 
face of choroid, showing how they disturb the outer layers of the retina. 
X 60. 

Probably it may result from various forms of choroiditis, 
and may also be a natural senile change. 

Hemorrhage from the choroidal vessels is not so often 












DISEASES OF THE CHOROID. 


221 


recognized as from those of the retina, but may be seen 
sometimes, especially in old people and in highly myopic 
eyes. The patches are more rounded than retinal hemor¬ 
rhages, and we can sometimes recognize the striation of the 
overlying retina. Occasionally they are of immense size. 
Patches of atrophy may follow. 

Clinical Forms of Choroidal Disease. 

1. Numerous discrete patches of choroidal atrophy (some¬ 
times complete, as if a round bit had been punched out, in 
others incomplete, though equally round and well defined) 
are scattered in different parts of the fundus, but are most 
abundant toward the periphery; or, if scanty, are found 
only in the latter situation. They are more or less pig¬ 
mented, unless the patient’s complexion is extremely fair. 
Fig. 81, c. 

2. The disease has the same distribution, but the patches 
are confluent; or large areas of incomplete atrophy, pass¬ 
ing by not very well-defined boundaries into the healthy 
choroid around, are interspersed with a certain number of 
separate patches; or without separate patches there may 
be a widely spread superficial atrophy with pigmentation. 
Fig. 81, a and b. 

These two types of choroiditis disseminata run into one 
another, different names being used by authors to indicate 
topographical varieties. Generally both eyes are affected, 
though unequally ; but in some cases one eye escapes. The 
retina and disk often show signs of past or present inflam¬ 
mation. 

Syphilis is by far the most frequent cause of symmetrical 
disseminated choroiditis. The choroiditis begins from one 
to three years after the primary disease, whether this be 
acquired or inherited ; occasionally at a later period. 

The discrete variety, Fig. 81, c, where the patches, though 


222 


CLINICAL DIVISION. 


usually involving the whole thickness of the choroid, are 
not connected by areas of superficial change, is the least 
serious form, unless the patches are very abundant. A 
moderate number of such patches, confined to the periphery, 
cause no appreciable damage to sight. The more super¬ 
ficial and widely-spread varieties, in which the retina and 
disk are inflamed from the first, are far more serious. The 
capillary layer of the choroid seldom again becomes healthy, 
and with its atrophy, even if the deeper vessels be not much 
changed, the retina suffers, passing into slowly progressing 
atrophy. The retina often becomes pigmented, Fig. 91, its 
bloodvessels extremely narrowed, bordered by white lines 
or sheathed in pigment, and the disk passes into a peculiar 
hazy-yellowish atrophy, “waxy disk” (Hutchinson); “ cho- 
roiditic atrophy” (Gowers). The appearances may closely 
imitate those in true retinitis pigmentosa, and the patient, 
as in that disease, often suffers from marked night-blind¬ 
ness. Such patients continue to get slowly worse for many 
years, and may become nearly blind. 

Syphilitic choroiditis generally gives rise, at an early 
date, to opacities in the vitreous; these either form large, 
easily seen, slowly floating, ill-defined clouds, or are so 
minute and numerous as to cause a diffuse and somewhat 
dense haziness, “ dust-like opacities,” (Forster). Chapter 
XVI. Some of the larger ones may be permanent. In the 
advanced stages, as in true retinitis pigmentosa, posterior 
polar cataract is sometimes developed. 

There are no constant differences between choroiditis in 
acquired and in inherited syphilis; in many cases it would 
be impossible to guess, from the ophthalmoscopic changes, 
with which form of the disease we had to do. But there 
is, on the whole, a greater tendency toward pigmentation in 
the choroiditis of hereditary than in that of acquired syph¬ 
ilis, and this applies both to the choroidal patches and to 
the subsequent retinal pigmentation. 


DISEASES OF THE CHOROID. 


900 

/jZi* > 


In the treatment of syphilitic choroiditis we rely almost 
entirely on the constitutional remedies for syphilis—mer¬ 
cury and iodide of potassium. In cases which are treated 
early, sight is much benefited, and the visible exudations 
quickly melt away under mercury ; but I believe that even 
in these complete restitution seldom takes place, the nutri¬ 
tion and arrangement of the pigment epithelium and bacil¬ 
lary layer of the retina being quickly and permanently 
damaged by exudations into or upon the chorio-capillaris, 
as in Fig. 82. In the latter periods, when the choroid is 
thinned by atrophy, or its inner surface roughened by little 
outgrowths, Fig. 83, or when adhesions and cicatricial con¬ 
tractions have occurred between it and the retina, nothing 
can be done. A long mercurial course should, however, 
always be tried if the sight be still failing, even if the 
changes all look old; for in some cases, even of very long 
standing, fresh failure takes place from time to time, and 
mercury has a very marked influence. In acute cases rest 
of the eyes in a darkened room, and the employment of 
the artificial leech or of dry cupping at intervals of a few 
days, for some weeks, are useful. But it is often difficult 
to ensure such functional rest, for the patients seldom have 
pain or other discomfort. 

Disseminated choroiditis sometimes occurs without ascer¬ 
tainable evidence of syphilis, chiefly about the age of 
puberty. Such cases often differ in some of their ophthal¬ 
moscopic details from ordinary syphilitic cases, especially 
in the immunity of the retina and disk ; and also in the 
absence of tendency to recur. It is but seldom that any 
definite cause, such as exposure to bright light, can be 
plausibly assigned. 

In choroiditis from any cause iritis may occur. 

3. The choroidal disease is limited to the central region. 
There are many varieties of such localized change. 

In myopia the elongation which occurs at the posterior 


224 


CLINICAL DIVISION 


pole of the eye very often causes atrophy of the choroidal 
contiguous to the disk, and usually only on the side next 
the yellow spot (see Myopia). The term posterior staphy¬ 
loma is applied to this form of disease when the eye is 
myopic, because the atrophy is a sign of posterior bulging 
of the sclerotic. The term sclerotico-choroiditis posterior is 
often used, though we but seldom see evidence of exudative 
changes or hemorrhagic effusions at the fundus in myopia. 
A similar crescent, but seldom of great width, is very com¬ 
monly seen bounding the lower margin of the disk in astig¬ 
matic eyes; its widest part nearly always corresponds with 
the direction of the meridian of greatest curvature of the 
cornea. Chapter XX. A narrow and less conspicuous 
crescent or zone of atrophy around the disk is seen in some 
other states, notably in old persons, and in glaucoma. Sepa¬ 
rate round patches of complete atrophy, “ punched-out 
patches,” at the central region may occur in myopia with 
the above-mentioned staphyloma, and must not then be 
ascribed to syphilitic choroiditis; in other cases of myopia 
ill-defined partial atrophy is seen about the y. s., sometimes 
with spilts or lines running horizontally toward the disk. 

Central senile choroiditis. Several varieties of disease 
confined to the region of the y. s. and disks are seen, and 
chiefly in old persons. One of these, known as central senile 
areolar choroiditis, is characterized by a white patch, often 
very large, occupying the whole central region of the fun¬ 
dus ; the particularly striking and rather rare form shown 
in Fig. 86 may be a late stage of the former. In others a 
larger but less defined area is affected; some of these ap¬ 
pearances undoubtedly result from large choroidal or reti¬ 
nal extravasation. In these areated forms the large deep 
vessels are often much narrowed, or even converted into 
white lines devoid of blood-color, by thickening of their 
coats. In another form, Fig. 87, the central region is occu¬ 
pied by a number of small white or yellowish-white dots, 




DISEASES OF THE CHOROID. 225 

sometimes visible only in the erect image. This condition 
is very peculiar, and appears to be almost stationary; the 


Fig. 86. 


Central choroiditis. (Wecker and Jaeger.) 
Fig. 87. 


Central guttate senile choroiditis. 

15 
















































226 


CLINICAL DIVISION. 


disks are sometimes decidedly pale; when very abundant 
the spots coalesce, and some pigmentation is found. The 
pathological anatomy and general relations of this disease 
are incompletely known, but the white dots are probably 
due to a hyaline degeneration of the pigment epithelium 
of the retina; it was first described by Hutchinson and 
Tay, and is tolerably common. It is symmetrical, and the 
changes may sometimes be mistaken for a slight albuminuric 
retinitis. No treatment seems to have any influence. Every 
case of immature cataract should, when possible, be exam¬ 
ined for central choroidal changes. 

4. Suppurative choroiditis and iridochoroiditis. In this 
affection an exudation into the vitreous is produced, which 
appears as a yellow mass in the fundus of the eye. The 
inflammation spreads to the ciliary body and iris, and the 
whole globe becomes congested; panophthalmitis may set 
in, or the eye may undergo softening and shrink. This is 
due to (1) infection by pyogenic organisms from penetrating 
wounds or perforating ulcers ; (2) infection from within by 
septic embolism as in pyaemia (metastatic choroiditis), or 
by extension of inflammation from behind as in thrombosis 
of the orbital veins, and in meningitis. The latter occurs 
mostly in children, and is sometimes known as pseudo-glioma 
from its resemblance to glioma of the retina. In these 
cases iritic adhesions are usually present, T. is —, the eye 
somewhat shrunken, the anterior chamber deep at its 
periphery, while absent or shallow at the centre. There is 
often the history of some illness with a definite inflamma¬ 
tion of the eye before the change is noticed in the pupil. 
The differential diagnosis from glioma is occasionally very 
difficult, and in case of doubt it is better to excise the eye 
(see Glioma, Chapter XVIII.) 

5. Anomalous forms of choroidal disease. Single large 
patches of atrophy, with pigmentation, not located in any 
particular part, are occasionally met with. Probably some 


DISEASES OF THE CHOROID. 


227 


of these have followed the absorption of tubercular growths 
iu the choroid, while others are the result of large sponta¬ 
neous hemorrhages. A blow by a blunt object on the scle¬ 
rotic causing local bleeding, or inflammation and subse¬ 
quent atrophy, may account for such a patch at the 
anterior part of the fundus. Single large patches of exu¬ 
dation are also met with, and are perhaps tubercular. 

Choroidal disease in disseminated patches seems some¬ 
times to depend upon numerous scattered hemorrhages into 
the choroid, which may occur at different dates, and may 
lead to patches of partial atrophy with pigmentation. The 
local cause of such hemorrhages is obscure; the disease 
may occur in one eye or both, and in young adults of either 
sex. It may perhaps be called hemorrhagic choroiditis 
(compare Chapter XVI.) Although the changes produced 
are very gross, some of these patients regain almost perfect 
sight—a fact perhaps pointing to the deep layers of the 
choroid as the seat of disease. It is possible that over-use 
of the eyes, or exposure to great heat or glare, sometimes 
causes choroiditis. 

Single spots of choroidal atrophy, especially toward the 
periphery, should, no less than abundant changes, always 
excite grave suspicion of former syphilis, and often furnish 
valuable corroborative evidence of that disease. The periph¬ 
ery cannot be fully examined unless the pupil be widely 
dilated. A few small, scattered spots of black pigment on 
the choroid, or in the retina, without evidence of atrophy 
of the choroid, often indicate former hemorrhages. Such 
spots are seen after recovery from albuminuric retinitis 
with hemorrhages, after blows on the eye, and sometimes 
without any relevant history. 

Congestion of the choroid is not commonly recognizable 
by the ophthalmoscope. That active congestion does occur 
is certain, and it would seem that myopic eyes are espe¬ 
cially liable to it, particularly when over-used or exposed 


228 


CLINICAL DIVISION. 


to bright light and great heat. Serious hemorrhage may 
undoubtedly be excited under such circumstances. In con¬ 
ditions of extreme anaemia the whole choroid becomes 
unmistakably pale. 

Coloboma of the choroid, congenital deficiency of the 
lower part, is shown ophthalmoscopically by a large sur¬ 
face of exposed sclerotic, often embracing the disk, which 
is then much altered in form, and may be hardly recog¬ 
nizable, and extending downward to the periphery, where 
it often narrows to a mere line or chink. The surface of 
the sclerotic, as judged by the course of the retinal vessels, 
is often very irregular, from bulging of its floor backward. 
The coloboma is occasionally limited to the part around 
the nerve, or may form a separate patch. Coloboma of 
the choroid is often seen without coloboma of the iris, and 
when both exist a bridge of choroidal tissue generally sepa¬ 
rates them in the region of the ciliary body. Cases of 
so-called coloboma of the choroid at the yellow spot are 
probably examples of severe foetal or infantile inflamma¬ 
tion of that part. 

Albinism is accompanied by congenital absence of pig¬ 
ment in the cells of the epithelium and stroma of the whole 
uveal tract, choroid, ciliary processes, and iris. The pupil 
looks pink, because the fundus is lighted, to a great extent, 
indirectly through the sclerotic. Sight is always defective, 
and the eyes photophobic and usually oscillating. Many 
almost albinotic children become moderately pigmented as 
they grow up. 


i 







PLATE I. 



Fig. 1.—Normal Eye-ground (average tint). 



Fig. 2.— Normal Eye-ground (brunette). 






CHAPTER XIJT. 


DISEASES OF THE RETINA. 

Of the many morbid changes to which the retina is sub¬ 
ject, some begin and end in this membrane, such as albu¬ 
minuric retinitis and many forms of retinal hemorrhage; 
in others the retina takes part in changes which begin in 
the optic nerve (neuro-retinitis), or in the choroid (choroido- 
retinitis); very serious lesions also occur from embolism or 
thrombosis of the central retinal vessels. The retina may 
be separated (“ detached ”) from the choroid by serous fluid 
or blood. The retina may also be the seat of malignant 
growth (glioma), and probably of tubercular inflammation. 

In health the human retina is so nearly transparent as 
to be almost invisible by the ophthalmoscope during life, 
or to the naked eye if examined immediately after excision. 
We see the retinal bloodvessels, but the retina itself, as a 
rule, we do not see. The main bloodvessels are derived 
from the arteria and vena centralis , which enter the outer 
side of the optic nerve, about 6 mm. behind the eye; the 
veins and arteries are generally in pairs, the veins not being 
more numerous than the arteries; all pass from or to the 
optic disk. Fig. 37. At the disk anastomoses, chiefly 
capillary, are formed between the vessels of the retina and 
those of the choroid and sclerotic. As no other anasto¬ 
moses are formed by the vessels of the retina, the retinal 
circulation beyond the disk is terminal; and, further, as 
the vessels branch dichotomously, and the branches anas¬ 
tomose only by means of their capillaries, the circulation 
of each considerable branch is terminal also. The capil¬ 
laries, which are not visible by the ophthalmoscope, are 

( 229 ) 


230 


CLINICAL DIVISION. 


narrower than those of the choroid, and their meshes be¬ 
come much wider toward the anterior and less important 
parts of the retina. 

At the y. s., Fig. 88, the only part used for accurate sight, 
the capillaries are very abundant, compare Fig. 79; but at the 
very centre of this region, fovea centralis , where all the layers 
except the cones and outer granules are excessively thin, there 
are no vessels, the capillaries forming fine, close loops just 
around it. The nerve-fibres in this part of the retina are finer 
than in other parts; they seem also to be much more abun¬ 
dant, for Bunge has found that in a case of central scotoma, 
where only a very small part of the F. was lost, quite a 
large tract of fibres (f of the whole) was atrophied in the 
optic nerve. The fovea centralis corresponds to an area at the 
centre of F., measuring only 1|° in diameter; the part recog¬ 
nized as the macula lutea has an area, on the F., of about 7° 
(Bunge). 

Fig. 88. 



V A V A V 


Bloodvessels of human retina at the yellow spot (artificial injection). The 
central gap corresponds to the fovea centralis, a. Arteries, y. Veins. 
N. Nasal side (toward disk). T. Temporal side. The meshes are many times 
wider at the periphery of the retina. 

In children, especially those of dark complexion, a pecu¬ 
liar white, shifting reflection, or shimmer, is often seen at 
the y. s. region, and along the course of the principal ves¬ 
sels. It changes with every movement of the mirror, and 
reminds one of the shifting reflection from “watered” 
and “ shot” silk. Around the y. s. it tabes the form of a 










DISEASES OF THE RETINA. 


231 


ring or zone, and is known as the “ halo round the macula.” 
When the choroid is highly pigmented, even if this shifting 
reflection be absent, the retina is visible as a faint haze over 
the choroid like the “ bloom ” on a plum. Under the high 
magnifying power of the erect image the nerve-fibre layer is 
often visible near the disk as a faintly-marked radiating 
striation. The sheaths of the large central vessels at their 
emergence from the physiological pit show many variations 
in thickness and opacity. 

In rare cases the medullary sheath of the optic nerve- 
fibres, which should cease at the lamina cribrosa, is con¬ 
tinued through the disk into the retina, and causes the 
ophthalmoscopic appearance known as “ opaque nerve- 
fibres.” This congenital peculiarity may affect the nerve- 
fibres of the whole circumference of the disk, or only a 
patch or tuft of the fibres; it may only just overlap the 
edge of the disk, or may extend far into the retina; and 
islands of similar opacity are sometimes seen in the retina 
quite separated from the disk. It is to be particularly 
noted that the central part, physiological pit, of the disk is 
not affected, because it contains no nerve-fibres. The 
affected patch is pure white, and quite opaque; its margin 
thins out gradually, and is striated in fine lines, which 
radiate from the disk like carded cotton-wool; the retinal 
vessels may be buried in the opacity, or run unobscured on 
its surface, and are of normal size. The deep layers of the 
affected parts of the retina being obscurbed by the opacity, 
an enlargement of the normal “ blind spot” is the result. 
One eye, or both, may be affected. There is seldom any 
difficulty in distinguishing this condition from opacity due 
to neuro-retinitis. 

Ophthalmoscopic Signs of Retinal Disease. 

Congestion. No amount of capillary congestion, whether 
passive or active, alters the appearance of the retina; and 


232 


CLINICAL DIVISION. 


as to the large vessels, it is better to speak of the arteries 
as unusually large or tortuous, or of the veins as turgid or 
tortuous, than to use the general term congestion. Capil¬ 
lary congestion of the optic disk may undoubtedly be recog¬ 
nized ; but even here caution is needed, and much allowance 
must be made for differences of contrast depending on vari¬ 
ations in the tint of the choroid, for the patient’s health 
and age, and for the brightness of the light used, or, what 
is the same thing, for the size of the pupil. Caution is also 
needed against drawing hasty inferences from the slight 
haziness of the outline of the disk, which may often be seen 
in cases of hypermetropia, and which is certainly not always 
morbid. 

The ouly ophthalmoscopic proof of true retinitis is loss 
of transparency of the retina, and two chief types are soon 
recognized according as the opacity is diffused, or consists 
chiefly of abrupt spots and patches. Hemorrhages are 
present in many cases of retinitis ; but they may also occur 
without either inflammation or oedema. The state of the 
disk varies much, but it seldom escapes entirely in a case 
of extensive or prolonged retinitis. In a large majority of 
cases of recent retinitis the visible changes are limited to 
the central region, where the retina is thickest and most 
vascular. 

1. The lessened transparency which accompanies diffuse 
retinitis simply dulls the red choroidal reflex, and the term 
“smoky’' is fairly descriptive of it. The same effect is 
given by slight haziness of any of the anterior media, but 
a mistake is excusable only when there is diffused mistiness 
of the vitreous from opacities which are too small to be 
easily distinguished (Chapter XVI.), and the difficulty is 
then increased because this very condition of the vitreous 
often co-exists with retinitis. A comparison of the erect 
and inverted images is often useful; for if the diffused haze 
noticed by indirect examination be caused by retinitis, the 


DISEASES OF THE RETINA. 


233 



direct examination will often resolve what seemed an uni¬ 
form haze into a well-marked spotting or streaking. When 
the change is pronounced enough to cause a decidedly white 
haze of the retina there is no longer any doubt. The retinal 
arteries and veins are sometimes enlarged and tortuous in 
retinitis, and in severe cases they are generally obscured in 
some part of their course. These forms of uniformly dif¬ 
fused retinitis are usually caused either by syphilis, embol¬ 
ism, or thrombosis. 

Fig. 89. 


Albuminuric retinitis. (Liebkeich.) 


2. Near the y. s. a number of small, intensely white, 
rounded spots are seen, Fig. 89, either quite discrete or 
partly confluent. When very abundant and confluent 



234 


CLINICAL DIVISION. 


partly confluent. When very abundant and confluent 
they form large, abruptly outlined patches, with irregular 
borders, some parts of these patches being striated, others 
stippled. 

3. A number of separate patches are scattered about the 
central region, but without special reference to the y. s. 
They are of irregular shape, white or pale buff, and some¬ 
times striated, Fig. 90; they are easily distinguished from 
patches of choroidal atrophy by their color, the compara¬ 
tive softness of their outlines, and the absence of pigmen¬ 
tation. 

In types 2 and 3 some hemorrhages are usually present; 
the retina generally may be clear, but more often there is 
diffused haze and evidence of swelling. The hemorrhages 
may be so numerous and large as to form the chief feature, 
and then the retinal veins will be very tortuous and dilated. 


Fig. 90. 



Recent severe retinitis in renal disease. (Gowers.) 


Forms 2 and 3, which nearly always affect both eyes, are 
generally associated with renal disease, but in rare cases 


































































































































DISEASES OF TIIE RETINA. 


235 


similar changes are caused by cerebral disease and other 
conditions. 

4. Rarely a single large patch or area of white opacity 
is seen with softened, ill-defined edges, any retinal vessels 
that may cross it being obscured. Such a patch of retinitis 
is usually caused either by subjacent choroiditis or by local 
phlebitis or thrombosis. 

Hemorrhage into (or beneath) the retina is known by its 
color, which is darker than that of an ordinary choroid, 
but redder and lighter than that of a very dark choroid. 
Blood may be effused into any of the retinal layers, and 
the shape of the blood patches is mainly determined by 
their position. When effused into the nerve-fibre layer, 
or confined by the sheath of a large vessel, the extravasa¬ 
tion takes a linear or streaked form and structure, follow¬ 
ing the direction of the nerve-fibres; extravasations in the 
deeper layers are rounded. Very large hemorrhages, many 
times as large as the disk, sometimes occur near the yellow 
spot, and probably all the layers then become infiltrated, 
while sometimes the blood ruptures the anterior limiting 
membrane of the retina and passes into the vitreous. 

Retinal hemorrhages may be large or small, single or 
multiple; limited to the central region or scattered in 
all parts; linear, streaky or flame-shaped, punctate or 
blotchy; they may lie alongside large vessels, or have no 
apparent relation to them. The hemorrhage may, as 
already mentioned, be the primary change, or may only 
form part of a retinitis or papillo-retinitis. A hemor¬ 
rhage which is mottled, and of dark, dull color, is gener¬ 
ally old. The rate of absorption varies very much; 
hemorrhage after a blow is very quickly absorbed, while 
effusions caused by the rupture of diseased vessels in old 
people, or accompanying retinitis from constitutional 
causes, often last for months, and leave permanent traces. 

Pigmentation of the retina has been referred to in con- 


236 


CLINICAL DIVISION. 


nection with choroiditis. Whenever pigment in the fundus 
forms long, sharply-defined lines, or is arranged in a mossy, 
lace-like or reticulated pattern, we may safely infer that it 
is situated in the retina, and generally that it lies along the 
sheaths of the retinal vessels. Compare Fig. 91 with Fig. 
78. Pigment in or on the choroid never takes such a pat¬ 
tern, being usually in blotches or rings. The two types, 
however, are often mingled in cases of choroiditis with 
secondary affection of the retina; indeed, whenever we 
decide that the retina is pigmented, the choroid must be 
carefully examined for evidences of former choroiditis. 


Fig. 91. 



Study of pigment in the retina in a specimen of secondary retinitis 
pigmentosa, seen from the inner (vitreous) surface. 


Spots of pigment may be left after the absorption of retinal 
hemorrhages. Such spots can generally be distinguished 
from those following choroiditis by their more uniform ap¬ 
pearance and by the absence of signs of choroidal atrophy. 

Atrophy of the retina, of which pigmentation of the 
retina, when present, is always a sign, has for its most 
constant indication a marked shrinking of the retinal 
bloodvessels, with thickening of their coats. When the 
atrophy follows a retinitis or choroido-retinitis (retinitis 
pigmentosa, syphilitic choroido-retinitis, etc.), all the layers 
are involved, and the outer layers, those nearest the cho¬ 
roid, earlier than the inner; but when it is secondary 
to disease of the optic nerve, optic neuritis, progressive 
atrophy, and glaucoma, only the layers of nerve-fibres and 
ganglion-cells are atrophied, the outer layers being found 
perfect even after many years. A retina atrophied after 


DISEASES OF THE RETINA. 


237 


retinitis often does not regain perfect transparency, and if 
there have been choroiditis the retina remains especially 
hazy in the parts where this has been most severe. 

The disk after severe retinitis or choroido-retinitis always 
passes into atrophy, often of peculiar appearance, being 
pale, hazy, homogeneous-looking, and with a yellowish or 
brownish tint. 

Detachment (separation) of the retina. As there is no 
continuity of structure between the choroid and retina, 
the two may be easily separated by effusion of blood or 
serous fluid, the result either of injury or disease, by morbid 
growths, and by the traction of fibrous cords in the vit¬ 
reous. Such fibrous bands and strings develop in the 
vitreous in some cases of iridocyclitis, and perhaps in 
myopic eyes without signs of inflammation. Occasionally 
rents may be seen in the separated retina. It has been 
suggested that such rents occurring while the retina was 
still in situ might initiate the detachment by allowing the 
intrusion of vitreous between the retina and choroid; and 


Fig. 92. 



Section of eye with partial detachment of retina. 

this explanation may possibly hold good in very myopic 
eyes. The retina is separated at the expense of the vit¬ 
reous, which is proportionately absorbed, but always remains 
attached at the disk and ora serrata, unless as the result of 
wound or great violence. The depth, area, and situation 
of the detachment are subject to much variety. Fig. 92 
shows a diagrammatic section of an eye in which the lower 



238 


CLINICAL DIVISION. 


part of the retiua is separated. The pigment epithelium 
always remains on the choroid. 

The separated portion is usually far within the focal 
length of the eye; its erect image is, therefore, very easily 
visible by the direct method, when it appears as a gray or 
whitish reflection in some part of the field, the remainder 
being of the natural red color; the detached part is gray 


Fig. 93. 



Detachment of retina. 


or whitish, because the retina has become opaque. With 
care we can accurately focus the surface of the gray reflec¬ 
tion, observe that it is folded, and see one or more retinal 
vessels meandering upon it in a tortuous course; they ap¬ 
pear small and of dark color, and have lost their central 
light streak. If the separation be deep, the outline of its 
more promiuent folds, Fig. 93, can be seen standing out 
sharply against the red background, and in some cases the 


DISEASES OF THE RETINA. 


239 


folds flap about when the eye is quickly moved. In ex¬ 
treme cases we can see the detached part by focal light. 
When the detachment is recent, especially if shallow, the 
choroidal red is still seen through it; the diagnosis then 
rests on the observation of whether the vessels in any part 
are darker, smaller, and more tortuous than elsewhere, and 
upon ophthalmoscopic estimation of the refraction of the 
retinal vessels at different parts of the fundus, for the de¬ 
tached part will be much more hypermetropic than tire 
rest. In very high myopia a shallow detachment may 
still lie behind the principal focus, and therefore not 
yield an erect image without a suitable concave lens; in 
such a case, and in others where minute rucks or folds of 
detachment are present, examination by the direct method 
leads to a right diagnosis; as the image of the detached 
portion is not in focus at the same moment as its surround¬ 
ing parts, parallactic movement} is obtained, and the vessels 
are tortuous. Deep and extensive detachment is often 
associated with opacities in the vitreous or lens, or with 
iritic adhesions; and any of these conditions interfere with 
the conclusive application of the above tests. In some 
cases of detachment large patches and streaks of choroidal 
disease are to be found. The treatment of detachment of 
the retina is very unsatisfactory, improvement if obtained 
being seldom permanent, even when treatment is under¬ 
taken soon after the detachment has occurred. Puncture 
of the sclerotic over the detachment is occasionally fol¬ 
lowed by marked improvement, and the result is said to 
be better if the sclerotic be laid bare by dissecting up the 
conjunctiva before the puncture, and if the puncture be 
rather broad, about 2 to 4 mm.; the subretinal fluid rap¬ 
idly drains away. The conjunctival wound should be 


1 On closing one eye and viewing two objects, one beyond the other, but 
in the same line, one object seems to move over the other when the head is 
moved from side to side. 


240 


CLINICAL DIVISION. 


sutured. Profuse sweating and salivation, induced by 
pilocarpine (F. 41), have been recommended in recent 
cases. Mere rest in bed for some days in a subdued light, 
with the eyes tied up, is often followed for a time by decided 
improvement of sight. The best results seem to have been 
obtained by this means, combined with scleral puncture, 
in recent cases. 

Clinical Forms of Retinal Disease. 

The symptoms of retinal disease relate only to the failure 
of sight which they cause, and this may be either general, 
or confined to a part of the field, according to the nature 
of the case. Neither photophobia nor pain occurs in 
uncomplicated retinitis. 

Syphilitic retinitis is generally associated with, and sec¬ 
ondary to, choroiditis, but the retinitis may be primary. 
The vitreous in this disease, as in syphilitic choroiditis, is 
often hazy, and the opacities are sometimes seated deeply, 
just in front of the retina. The changes are those of dif¬ 
fuse retinitis, with slight “smoky” haze, often confined 
to the region of the yellow spot or disk; but in bad cases 
the haze passes into a whiter mistiness, and extends over a 
much larger region; sometimes long, branching streaks 
or bands of dense opacity are met with, and hemorrhages 
may occur. The disk is always hazy, and at first too red, 
while the retinal vessels, both arteries and veins, are some¬ 
what turgid and tortuous; rarely the disk becomes opaque 
and swollen. At a late period, in unfavorable cases, the 
vessels shrink slowly, almost to threads, the retina often 
becomes pigmented at the periphery, and the pigmented 
epithelium disappears, 

Syphilitic retinitis is one of the secondary symptoms, 
seldom setting in earlier than six or later than eighteen 
months after the primary disease. It occurs in congenital 
as well as acquired syphilis. It generally attacks both 


DISEASES OF THE RETINA. 


241 


eyes, though often with an interval. Its onset is often 
rapid, as judged by its chief symptom, failure of sight, 
and it may be stated that, as a rule, the degree of ambly¬ 
opia is much higher than would be expected from the 
ophthalmoscopic changes. Night-blindness is often a pro¬ 
nounced symptom. Its course is chronic, seldom lasting 
less than several months, and it shows a remarkable ten¬ 
dency, for many months, to repeated and rapid exacerba¬ 
tions after temporary recoveries, but with a tendency to 
get worse rather than permanently better. Among the 
early symptoms are often a “ flickering” and micropsia; 
these, with the history of variations lasting for a few days 
and of marked night-blindness, often lead to a correct sur¬ 
mise before ophthalmoscopic examination. There is, how¬ 
ever, nothing pathognomonic in any of the symptoms. An 
annular defect in the visual field (“ ring scotoma”) may 
often be found if sought; in the late stages the field is 
contracted. 

Mercury produces most marked benefit, and when used 
early it permanently cures a large proportion of the cases; 
but in a number of cases, perhaps in those where there is 
most choroiditis, the disease goes slowly from bad to worse 
for several years, in spite of very prolonged mercurial 
treatment. Of the efficacy of prolonged disuse of the 
eyes, and of local counter-irritation or depletion, strongly 
recommended by many authors, I have had but little 
experience. 

Albuminuric retinitis (papillo-retinitis). The changes 
are strongly marked, and so characteristic that it is pos¬ 
sible, in most cases, to say from an ophthalmoscopic exami¬ 
nation alone that the patient is suffering from kidney dis¬ 
ease. In the sclerosis of the arteries which accompanies 
chronic renal disease the retinal arteries frequently have 
an unusually bright and sharp central light streak, and 
are of a lighter color than normal; they have much the 

16 


242 


CLINICAL DIVISION. 


Fame appearance as would be presented by a piece of bright 
copper wire (Gunn). Where these arteries cross the veins 
the blood-current in the latter is interrupted. 

The earliest change, the stage of oedema and exudation, 
is a general haze of grayish tint in the central region of 
the retina, mostly with some hemorrhages and soft-edged 
whitish patches, and with or without haze and swelling of 
the disk. In this stage the sight is often unimpaired, so 
the cases are seldom seen by ophthalmic surgeons till a few 
weeks later, when the translucent, probably albuminous 
exudations in the swollen retina have passed into a state 
of fatty or fibrinous degeneration, a change which affects 
both the nerve-fibres and connective tissue. 

In the second stage we find a number of pure white dots, 
spots, or patches in the hazy region, and especially grouped 
around the yellow spot. Their peculiarity is their sharp 
definition and pure, opaque white color; indeed, when 
small and round they are almost glistening. When not 
very numerous they are generally confined to the yel¬ 
low-spot region, from which they show a tendency to 
radiate in lines; when very small and scanty they may 
be overlooked unless we examine the erect image; but 
frequently large patches are formed by the confluence of 
small spots, and the borders of these patches are striated, 
crenated, or spotted. At this stage the soft-edged patches, 
Fig. 90, have often to a great extent disappeared, or be¬ 
come merged into more general opacity of the retina; the 
disk is hazy and somewhat swollen, especially just at its 
margin, and the retina, as judged by the undulations of 
its vessels and confirmed by post-mortem examination, is 
much thickened. Hemorrhages are generally still present, 
and occasionally they constitute the most marked feature; 
they are usually striated. Sometimes an artery is seen 
sheathed by a dense white coating. 1 In another group 

1 Illustrations of this are given in Gowers’ Medical Ophthalmoscopy, pi. 
xii. fig. 1, and in Transactions of Ophthalmic Society, vol. ii. pi. ii. 


DISEASES OF THE RETINA. 


243 


papillitis is the most marked change, though some bright 
white retinal spots are always to be found by careful 
examination. 

The usual tendency is toward subsidence of the oedema 
and absorption of the fatty deposits and extravasations, 
generally with improvement of sight—the third stage, or 
stage of absorption and atrophy. 

In the course of several months the white spots diminish 
in size and number, until only a few very small ones are 
left near the yellow spot, with perhaps some residual haze: 
the blood-patches are slowly absorbed, often leaving small, 
round pigment spots, and the retinal arteries may be 
shrunken. In cases of only moderate severity almost 
perfect sight is restored. But when the optic disk suffers 
severely (severe papillitis), or if the retinal disease be ex¬ 
cessive, and attended by great oedema, sight either im¬ 
proves very little, or, as the disk passes into atrophy and 
the retinal vessels contract, it may sink to almost total 
blindness. Such a condition may be mistaken for atrophy 
after cerebral neuritis; but the presence of a few minute 
bright dots or of some superficial disturbance of the cho¬ 
roid at the yellow spot, or of some scattered pigment spots 
left by extiavasations, will generally lead to a correct in¬ 
ference. In the cases attended by the greatest swelling 
and opacity of retina and disk, death often occurs before 
retrogressive changes have taken place. In extreme 
cases the retina may become deeply detached from the 
choroid. 

Albuminuric retinitis is almost invariably symmetrical, 
but seldom quite equal in degree or result in the two eyes. 

The kidney disease in the malady under consideration is 
nearly always chronic. The retinitis may occur in any 
chronic nephritis and in the albuminuria of pregnancy. 
Whatever be the form of the kidney disease, the retinitis 
usually occurs with other symptoms of active kidney mis- 


244 


CLINICAL DIVISION. 


chief, such as headache, vomiting, loss of appetite, and 
often anasarca; but occasionally the retinitis is the first 
recognizable sign. The quantity of albumin varies very 
much. In the absence of anasarca the symptoms are often 
put down to “biliousness,” and as in such cases the failure 
of sight is the most troublesome symptom, the ophthalmo¬ 
scope often leads to the correct diagnosis. A second attack 
of retinitis sometimes occurs in connection with a relapse of 
renal symptoms. Many of the best marked cases of albu¬ 
minuric retinitis occur in the albuminuria of pregnancy, 
and the prognosis for sight is good in many of these if the 
symptoms come on sufficiently late in the pregnancy to 
permit of the cause being removed by the induction of 
artificial labor; but some of them, probably cases of old 
kidney disease, do very badly, and pass into atrophy of 
the nerves. 

Though the diagnosis of renal disease, based on the 
presence of the symmetrical retinal changes above de¬ 
scribed, will usually be verified by the physician, we do 
unquestionably now and then meet with cases of similar 
retinitis in which no kidney disease can be clinically 
proved. Trousseau describes several cases of this sort in 
which albumin appeared later. 1 Such cases need further 
attention. The cases of cerebral neuro-retinitis mentioned 
at p. 260, and rare cases of retinitis, exactly like renal 
retinitis but confined to one eye, have also to be allowed 
for. Retinal changes more or less like those above de¬ 
scribed are also found in other chronic general diseases— 
e. g., diabetes, pernicious anaemia, and leucocythaemia. 
Chapter XXIII. 

The term retinitis haemorrhagica has been given to cases 
characterized by very numerous linear or flame-shaped 
retinal hemorrhages, chiefly of small size, all over the 


1 Bull, de l’Hopital des Quinze-vingts, iv. 4,173. 


DISEASES OF THE RETINA. 


245 


fundus, or limited to the area of one vein, generally with 
extreme venous engorgement and retinal oedema, but in 
some cases without these features. It usually occurs in 
only one eye at a time, and comes on rapidly. The patients 
are often gouty or the subjects of disease of cardiac valves, 
or of the arterial system. Thrombosis of the trunk of the 
vena centralis retince is probably the determining cause of 


Fig. 94. 



Hemorrhagic retinitis. (Jaeger.) 


the condition 1 when there is much venous distention and 
retinal oedema; multiple disease of minute retinal vessels 
when these symptoms are absent. Retinitis hsemorrhagica, 
of whichever type, is not common. 

Other cases are seen where extravasations, varying much 
in size, number, and shape, are scattered in different parts 
of the fundus of one or both eyes. Some of them are prob- 

1 Hutchinson, Michel: Graefe’s Arch. f. Ophth., xxiv. 2. 


246 


CLINIC A L DI VISION 


ably allied to the above, but often the nature of the case 
is obscure, or the hemorrhages are related to senile degen¬ 
eration of vessels. Such cases have been called retinitis 
apoplectica. 

Lastly, in an important group, a single very large ex¬ 
travasation occurs on the surface of the retina beneath the 
internal limiting membrane from rupture of a large retinal 
vessel, probably a vein— sub hyaloid hemorrhage. The hem¬ 
orrhage is generally in the yellow-spot region ; in process of 
absorption it becomes mottled, the densest parts remaining 
longest, and, if seen in that condition for the first time, the 
case may be taken for one of multiple hemorrhages. These 
large extravasations cause great defect of sight, which comes 
on in an hour or two, but not with absolute suddenness. 
Absorption, in the several groups of cases just mentioned, 
is very slow. 

Hemorrhages may occur from blows on the eye. They 
are usually small and quickly absorbed, differing in the 
latter respect very much from the cases before described. 

Leukaemic retinitis is characterized by retinal hemor¬ 
rhages or by extravasations of white blood-corpuscles into 
the retina ; the veins are enlarged, flattened, and tortuous ; 
the color of the choroid is often pale yellow. Retinal 
hemorrhages and optic neuritis also occur in progressive 
pernicious anaemia. 

Diabetic retinitis. See Chapter XXIII. 

Embolism of the central artery of the retina, or of one 

or more of its main divisions, gives rise to a characteristic 
retinitis, the cause of which can in most cases be recog¬ 
nized at once if it be recent; while in old cases the 
appearances, taken with the history, lead to a right diag¬ 
nosis. Thrombosis of the artery causes similar changes. 

The leading symptom of embolism is the occurrence of 
an instantaneous defect of sight, which is found on trial to 
be limited to one eye; sometimes the feeling is as if one 


DISEASES OF TIIE RETINA. 


247 


eye had suddeuly become “shut,” the blindness being as 
sudden as that from quickly closing the lids; but whether 
the defect amounts to absolute blindness or not depends on 
the position and size of the plug. Many of the patients 
have evidence of cardiac disease. Chorea has been present 
in a few. In any case, owing to the temporary establish¬ 
ment of collateral circulation by the capillary anastomoses 
at the disk, the patient sometimes notices an improvement 
of sight a few hours after the occurrence. This improve¬ 
ment, however, is but slight, the collateral channels being 
quite insufficient to meet the demand; nor is it often per¬ 
manent, because the retina suffers very quickly from the 
almost complete stasis, oedema, and inflammation rapidly 
setting in and leading to permanent damage. 

If the case be seen within a few days of the occurrence, 
the red reflex of the choroid around the yellow spot and 
disk is quite obscured, or partially dulled, by a diffused 
and uniform white mist. The* opacity is greatest just 
around the centre of the yellow spot, where the retina is 
very vascular, Fig. 88, and where its cellular elements, 
ganglion and granule layers, are more abundant than 
elsewhere; but at the very centre of the white mist a 
small, round, red spot is generally seen, so well defined 
that it may be mistaken for a hemorrhage; it represents 
the fovea centralis, where the retina is so thin that the cho¬ 
roid continues to shine through it when the surrounding 
parts are opaque ; it is spoken of by authors as the “ cherry- 
red spot at the macula lutea.” This appearance is very 
seldom seen except after sudden arrest of arterial blood- 
supply, by embolism or thrombosis of the arteria centralis, 
and perhaps by hemorrhage into the optic nerve compres¬ 
ing the vessels; and of these causes embolism appears to 
be the most common. The haze surrounds and generally 
affects, the disk also, which soon becomes very pale. The 
small veins in the yellow-spot region often stand out with 


248 


CLINICAL DIVISION. 


great distinctness, being enlarged by stasis, and conspicuous 
from contrast with the white retina. Small hemorrhages 
are often present. The larger retinal vessels, “both arteries 
and veins, are more or less diminished at and near the 
disk, the arteries in the most typical cases being reduced 
to mere threads; both arteries and veins are, however, 
sometimes observed to increase in size as they recede from 
the disk. The arteries, however, are not always extremely 
shrunken in cases of retinal embolism, the variations de¬ 
pending upon the position and size of the plug— i. e., upon 
whether the occlusion is complete or not. The sudden and 
complete failure of supply to a single branch of a retinal 
artery is sometimes followed by its emptying and shrinking 
to a white cord almost immediately. In other cases the 
branch may for a time be little if at all altered in size; 
and yet its blood column may be quite stagnant, as is 
proved by the impossibility of producing pulsation in it 
by the firmest pressure on the globe, while the other 
branches respond perfectly to this test. Sometimes this 
pressure-test, which showed blockage of some or all 
branches shortly after the onset, again produces pulsa¬ 
tion a few days later without visible evidence of collateral 
circulation, thus proving the re-establishment of the main 
channel. 

In from one to about four weeks the cloudiness clears 
off, and the disk passes into moderately white atrophy; 
the arteries, or some of them, according to the position 
of the plugging, are either reduced to bloodless white 
lines, or simply narrowed. 

Sight is almost always lost, or only perception of large 
objects retained, whatever be the final state of the blood¬ 
vessels. In the rare cases, where an embolus passes beyond 
the disk, and is arrested in the branch at some distance 
from it, the changes are confined to the corresponding 
sector of the retina, and a limited defect of the field is the 


DISEASES OF THE RETINA. 


249 


only permanent result. It is scarcely necessary to say 
that no treatment can be of any use in cases of lasting 
occlusion of the retinal arteries. It will be obvious, too, 
that these lesions will be limited to one eye, though a 
similar accident is occasionally seen afterward in the 
other. 

In a few cases sudden, simultaneous blindness of both 
eyes has occurred with extremely diminished retinal arte¬ 
ries, ischcemia retince, and iridectomy has been followed 
by return of sight, lower tension causing re-establishment 
of circulation. See also Quinine-blindness. 

Retinitis pigmentosa is a very slowly progressive sym¬ 
metrical disease, leading to atrophy of the retina, with 


Fig. 95. 



Extreme concentric contraction of field of vision (R.) in a case of advanced 
retinitis pigmentosa. The central dot shows the fixation point. The black 
shows the part lost. 

collection of black pigment in its layers and around its 
bloodvessels, and secondary atrophy of the disk. The 
earliest symptom is inability to see well at night, or by 
artificial light—night-blindness. Concentric contraction of 
the visual field soon occurs. Fig. 95. These defects may 
reach a high degree, while central vision remains excel¬ 
lent in bright daylight. The symptoms are noticed at an 
earlier stage by patients in whom the choroid is dark, and 
absorbs much light. 



250 


CLINICAL DIVISION. 


Ophthalmoscopic examination, where these symptoms 
have been present for some years, shows: (1) at the 
equator or periphery a greater or less quantity of pig¬ 
ment, arranged in a reticulated or linear manner, Fig. 


Fig. 96. 



Typical pigmentary degeneration of the retina. (Jaeger.) 


91, often with some small, separate dots; (2) in advanced 
cases, evidence of removal of the pigment epithelium, but 
no patches of choroidal atrophy ; (3) the pigment arranged 
in a belt, which is generally uniform, the pattern being 





DISEASES OF THE RETINA. 


251 


most crowded at the centre, and thinning out toward the 
borders of the belt; (4) that the changes are always sym¬ 
metrical, and the symmetry very precise. These appear¬ 
ances are quite characteristic of true retinitis pigmentosa. 
In addition, we find (5) diminution in size of the retinal 
bloodvessels, the arteries in advanced cases being mere 
threads; (6) a peculiar hazy, yellowish, “ waxy” pallor of 
the optic disk; (7) sometimes the pigmented parts of the 
retina are quite hazy; (8) posterior polar cataract and dis¬ 
ease of the vitreous are often present in the later stages. 
The latter changes (5 to 8), however, are found in many 
cases of late retinitis consecutive to choroiditis, and are 
not peculiar to the present malady. 

The disease begins in childhood or adolescence, progresses 
slowly but surely, and, as a rule, ends in blindness some 
time after middle life. A few cases of apparently recent 
origin are seen in quite aged persons, and a few are con¬ 
sidered to be truly congenital. The quantity of pigment 
visible by the ophthalmoscope varies much in cases of 
apparently equal duration, and is not in direct relation 
to the defect of sight; cases even occur, which certainly 
belong to the same category, in which no pigment is visible 
during life, the retina being merely hazy, though micro¬ 
scopical examination reveals abundance of minutely divided 
pigment (Poncet). The pathogenesis of the disease is not 
finally settled; it is at present doubtful whether there is 
from the first a slow sclerosis of the connective-tissue 
elements of the retina, with passage inward of pigment 
from the pigment epithelium, or whether the disease be¬ 
gins in the superficial layer of the choroid and the pig¬ 
ment epithelium. Its cause is obscure. It is undoubtedly 
strongly heritable, and many high authorities believe that 
it is really produced by consanguinity of marriage, either 
between the parents or near ancestors of the affected per¬ 
sons. Some of its subjects are of full mental and bodily 


252 


CLINICAL DIVISION. 


vigor; but many are badly grown, suffer from progressive 
deafness, and are defective in intellect. Although want 
of education, as a consequence of defective sight and hear¬ 
ing, may sometimes account for this result, we cannot thus 
explain the various defects and diseases of the nervous 
system which are not infrequently noticed in kinsmen of 
the patients. That the subjects of this disease should be 
discouraged from marrying is sufficiently evident. In a 
few cases galvanism has been followed by improvement 
both of vision and visual 1 field, but no other treatment 
has any influence. Complications such as cataract and 
myopia are not uncommon, and must be treated on gene¬ 
ral principles. 

It is sometimes very difficult to distinguish widely dif¬ 
fused and superficial choroiditis, with pigmentation of 
retina and atrophy of the disk, from true retinitis pig¬ 
mentosa. The question will generally relate to cause, as 
between retinitis pigmentosa and choroido-retinitis from 
syphilis. 

Retinal disease from intense light. A number of cases 
have now been observed in which blindness of a small 
area at the centre of the field has been caused by staring 
at the sun, usually during an eclipse. Corresponding to 
this functional defect, ophthalmoscopic evidences of cho¬ 
roiditis or choroido-retinitis have been found at the yellow 
spot. The defect often lasts for months, if not perma¬ 
nently. 2 

White connective-tissue strands are sometimes found 
in the retina either as the result of hemorrhages or as a 
primary inflammatory process; bloodvessels of new forma¬ 
tion are frequently seen, and from them repeated hemor¬ 
rhages occur into the retina or vitreous (retinitis proliferans). 

1 Gunn : Ophthalmic Hospital Reports, x. 161, and others. 

2 For accounts of cases and experiments on this affection, see London 
Medical Record, October, 1883; also Ophthalmic Review, April and May. 


DISEASES OF TIIE BE TIN A. 


253 


Retinitis circinata (Fuchs) occurs chiefly in old people, 
and consists in a gray degeneration of the retina at the 
yellow spot, surrounded by a brilliant white deposit of 
small dots which become confluent into large areas sur¬ 
rounding the central gray degeneration. The exact nature 
of this affection is unknown. 

1 For accounts of cases and experiments on this affection, see London Medi¬ 
cal Record, October, 1883; also Ophthalmic Review, April and May. 


CHAPTER XIV. 


DISEASES OF THE OPTIC NERVE. 

The optic nerve is often diseased in its whole length, or 
in some parts of its course, either within the skull, in the 
orbit, or at its ocular end. 

The effect of disease of the optic nerve in producing (1) 
ophthalmoscopic changes in its visible portion, the optic 
disk, or papilla optica , and (2) defect of sight, varies greatly 
according to the seat, nature, and duration of the disease. 
The appearance of the disk may be entirely altered by 
oedema and inflammation, without the nerve-fibres losing 
their conductivity, and, therefore, without loss or even de¬ 
fect of sight; on the other hand, inflammatory or atrophic 
changes, causing destruction of the nerve-fibres, may arise 
in the nerve at a distance from the eye, and, while pro¬ 
ducing great defect of sight, cause little or no immediate 
change at the disk. Although we are here concerned chiefly 
with the ophthalmoscopic and visual sides of the question, a 
few words are needed as to the morbid changes in the nerve. 

The pathological changes to which the optic nerve is 
liable include those which affect other nerve-tissues. In¬ 
flammation (optic neuritis, papillitis'), varying in seat, cause, 
and rapidity, and resulting in recovery or atrophy, may 
originate in the nerve itself, may pass down it from the 
‘brain (descending neuritis), or may extend into it from 
parts around ; atrophy may occur from pressure by tumors, 
or distention of neighboring cavities— e. g., the third ven¬ 
tricle—or from laceration of the nerve or its central vessels 
in the orbit, or damage from fracture of the optical canal; 
and the optic nerve is very subject to primary atrophy. 

( 254 ) 


PLATE II. 


Fig. 1 




Fig. 2.—Ophthalmoscopic Appearances in Regressive Neuritis. 




DISEASES OF THE OPTIC NERVE. 


255 


Lastly, the optic nerve.being surrounded by a lymphatic 
space, “subvaginal space,” which is continuous through 
the optic foramen with the meningeal spaces in the skull, 
and is bounded by a tough, fibrous “ outer sheath,” is 
liable to be affected by morbid processes going on in that 
space. This subvaginal or inter-sheath space, bounded 
externally by the outer sheath of the optic nerve, is lined 
internally by the inner sheath which is closely adherent to 
the nerve itself. Fig. 40. The relationship between optic 
neuritis and cerebral disease is still imperfectly understood. 
Widely differing kinds of intracranial disease, such as 
tumor or meningitis, produce an increase of fluid in the 
cavities of the brain. The increased pressure within the 
skull so produced leads to a distention of the subvaginal 
space of the optic nerve; this is frequently found post 
mortem. 

By many it is held that this alone is a sufficient cause of 
the optic neuritis, either by compressing the retinal veins 
and producing “ choked disk” (v. Graefe), or by setting 
up irritation in the nerve (Leber). The fact that optic 
neuritis very generally subsides after trephining the skull 
(Victor Horsley), even when the tumor is not removed, 
gives strong support to this pressure theory. 

On the other hand, it has been proved microscopically 
by many observers that the inflammation is not confined 
to the head of the nerve, but extends backward along its 
trunk to the substance of the brain, and is continuous with 
the inflammatory focus in the brain; this occurs not only 
in meningitis, but in remotely situated tumors, which are 
always surrounded by an area of hyperaemia. According 
to this view the inflammatory appearances in the head of 
the optic nerve are due to a descending neuritis} 

1 Gowers: Medical Ophthalmoscopy, Trans. Internat. Medical Congress, 
1881; papers by S. Mackenzie, Brailey, Edmunds and Lawford, and Taylor, 
Trans. Oph. Soc. 


256 


CLINICAL DIVISION. 


As already stated in previous chapters, inflammation may 
extend into the disk from the retina or choroid near to it, 
and may occur in consequence of the sudden arrest of the 
blood-current caused by embolism and thrombosis of the 
central retinal vessels in their course through the nerve. 

The ophthalmoscopic signs of papillitis are caused by 
varying degrees of oedema, congestion, and inflammation 
of the disk. It is no longer useful to maintain the old 
ophthalmoscopic distinction between “ swollen disk,” or 
“ choked disk,” and “ optic neuritis.” The latter term 
was formerly reserved for cases showing little oedema but 
much opacity, changes which were supposed especially to 
indicate inflammation passing down the nerve from the 
brain; but if oedema and venous engorgement predom¬ 
inated, “ choked disk,” the changes were attributed to 
compression of the optic nerve by fluid in its sheath-space, 
or with less reason to pressure on the ophthalmic vein at 
the cavernous sinus. The changes are often mixed, or vary 
at different stages of the same case. The terms “ neuritis ” 
and “papillitis” will be here used to the exclusion of 
“ choked disk.” 

The most important early changes in optic papillitis are 
blurring of the border of the disk by a grayish opalescent 
haze, distention of the large retinal veins, and swelling of 
the disk above the surrounding retina. Swelling is shown 
by the abrupt bending of the vessels, with deepening of 
their color and loss of the light streak—they are, in fact, 
seen foreshortened ; also by noticing that slight lateral 
movements of the observer’s head, or lens, cause an appar¬ 
ent movement of the vessels over the choroid behind, 
because the two objects are on different levels (“ parallactic 
test,” p. 239). The patient may die, or the disease may, 
after a longer or shorter time, recede at this stage. But 
further changes generally occur, the haziness becomes a 
decided opacity, which more or less obscures the central 


DISEASES OF THE OPTIC NER VE. 


257 


vessels, and covers and extends beyond the border of the 
papilla, Fig. 97, so that the disk appears enlarged; its 
color becomes a mixture of yellow and pink with gray or 
white, and it looks striated or fibrous, appearances due to 
a white opacity of the nerve-fibres mingled with numerous 
small bloodvessels and hemorrhages. The veins become 
larger and more tortuous, or even kinked or knuckled; the 
arteries are either normal or somewhat contracted; there 


Fig. 97. 



Ophthalmoscopic appearance of severe recent papillitis. Several elongated 
patches of blood near border of disk. Compare with Fig. 98. (After Hugh- 
lings Jackson.) 

may be blood-patches. The swelling of the disk may be 
very great, and is appreciated either by the above-men¬ 
tioned foreshortening of the vessels, by the parallactic test, 
or by ophthalmoscopic measurement. 

Such changes may disappear, leaving scarcely a trace; 
or a certain degree of atrophic paleness of the disk, with 
some narrowing of the retinal vessels and thickening of 
their sheaths, or other slight changes, may remain. But 

17 



258 


CLINICAL DIVISION 


in many cases the disk gradually, in the course of weeks 
or months, passes into a state of “ post-papillitic ” or “ con- 

Fig. 98. 



Section of the swollen disk in papillitis, showing that the swelling is limited 
to the layer of nerve-fibres (longitudinal shading); other retinal layers not 
altered in thickness. (Compare with Fig. 40). X about 15. 


Fig. 99. 



Atrophy of the disk after papillitis. Upper and lower margins still hazy; 
veins still tortuous; arteries nearly normal; disturbance of choroidal pig¬ 
ment at inner and outer border. Sight in this case remained fairly good. 
The disk is not represented white enough. 


secufive ” atrophy ; the opacity first becomes whiter and 
smoother looking (“ woolly disk’”); then it slowly clears 
off, generally first at the side next the yellow spot, and the 























































DISEASES OF THE OPTIC NERVE. 


259 


retinal vessels simultaneously shrink to a smaller size, 
though they often remain tortuous for a long time. Fig. 
99. As the mist lifts, the sharp edge, and finally the 
whole surface of the disk, now of a staring white color, 
again come into view. A slight haziness often remains, 
and the boundary of the disk is often notched and irreg¬ 
ular ; but upon these signs too much reliance must not be 
placed. 

Sight is seldom much affected 1 until marked papillitis 
has existed some little time. If the morbid process quickly 
cease, often no failure occurs; or the sight may fail, may 
even sink almost to blindness for a short time, and recov¬ 
ery may take place, if the changes cease before compression 
of the nerve-fibres have given rise to atrophy. Early blind¬ 
ness in double papillitis may be due to pressure on the 
chiasma or tracts rather than to the changes we see in the 
eyes. Gradual failure late in the case, when retrogressive 
changes are already visible at the disk, is a bad sign. The 
sight seldom changes, either for better or for Avorse, after 
the signs of acth r e papillitis have quite passed off; and 
though the relations between sight and final ophthalmo¬ 
scopic appearances vary, it is usually true (1) that great 
shrinking of the central retinal vessels indicates a high 
grade of atrophy and great defect of sight, and is generally 
accompanied by extreme pallor, with some residual hazi¬ 
ness of the disk—advanced post-papillitic atrophy ; (2) that 
considerable pallor and other slight changes, such as white 
lines bounding the vessels, or streaks caused by increase of 
the connective tissue of the disk, are compatible with fairly 
good sight if the central vessels are not much shrunken. 

Advanced atrophy, undoubtedly folloAving papillitis, does 


i Dr. Hughlings Jackson was the first to notice and insist upon the fre¬ 
quency of papillitis without failure of sight. The discovery Avas of immense 
value, for double papillitis, without other changes in the eye, is one of the 
most important objective signs wo possess of the existence of tumor, or 
inflammation, within the skull. 


260 


CLINICAL DIVISION. 


not, however, always show signs of the past violent inflam¬ 
mation ; the appearances may, indeed, be indistinguishable 
from those caused by primary atrophy. 

Papillitis is double in the great majority of cases. If 
single, it generally indicates disease in the orbit. It is true 
that single papillitis, from intracranial disease, is occasion¬ 
ally met with ; and that in many double cases inequalities 
are often seen between the two eyes, as to time of onset, 
degree, and final result. 

The changes are not always limited strictly to the disk 
and its border, pure papillitis, for in some cases a wide zone 
of surrounding retina is hazy and swollen, exhibiting hemor¬ 
rhages and Avhite plaques, or lustrous white dots— papillo¬ 
retinitis. It is not always easy to say, in such a case, 
whether the changes are due to renal disease, with great 
swelling of the disk, or to some intracranial malady. In 
renal cases there is albuminuria, the kidney is in an ad¬ 
vanced stage of disease, 1 and the patients are seldom young ; 
in the cases of neuro-retinitis most closely resembling renal 
cases, but caused by cerebral disease, there is no albumin, 
and the white deposits are seldom arranged quite as in 
renal retinitis, while the papillitis is greater than is usual 
in renal cases. 

Etiology (compare Chapter XXIII.). Papillitis occurs 
chiefly in cases of irritative intracranial disease, viz., in 
meningitis, both acute and chronic, and in intracranial new- 
growths of all kinds, whether inflammatory, syphilitic gum- 
niata, tubercular, or neoplastic. It is very rare in cases 
where there is neither inflammation nor tissue growth, as 
in cerebral hemorrhage and intracranial aneurism. Fur¬ 
ther, it must be stated that no constant relationship has 
beeu proved between papillitis and the seat, extent, or 
duration of the intracranial disease. Papillitis has occa- 


1 Gowers, p. 187. 


DISEASES OF THE OPTIC NERVE. 


261 


sionally been found without coarse disease, but with widely 
diffused minute changes, in the brain. Thus the occurrence 
of papillitis, although pointing very strongly to organic 
disease within the skull, and especially to intracranial 
tumor, is not of itself either a localizing or a differenti¬ 
ating symptom. Inflammation about the sphenoidal fis¬ 
sure, and tumors, nodes, and inflammations in the orbit, 
are occasional causes of papillitis, which is then usually 
one-sided, and often accompanied by extreme oedema and 
venous distention ; in some of these there is protrusion of 
the eye with affection of other orbital nerves, and the exact 
seat and nature of the disease may be obscure. Optic neu¬ 
ritis from intracranial disease seldom recurs after subsi¬ 
dence. 1 

Other occasional causes of double papillitis, with or with¬ 
out retinitis, are lead-poisoning, the various exanthemata, 
including recent syphilis, sudden suppression of menses, 
simple chronic anaemia, rapid copious loss of blood, espe¬ 
cially from the stomach, and, perhaps, exposure to cold. 
In a few cases well-marked double papillitis occurs without 
other symptoms, and without assignable cause. 

Certain cases of failure of sight, usually single, with 
slight neuritic changes at the disk, followed by recovery or 
by atrophy, must be referred to a local, primary optic neu¬ 
ritis some distance behind the eye, retro-ocular or retro-bulbar 
neuritis. The changes are, clinically, very different from 
those above described. 

Syphilitic disease within the skull is a common cause of 
papillitis, but the eye changes alone furnish no clue to the 
cause, nor to its mode of action, which may be (1) by 
giving rise to intracranial gumma, not in connection with 
the optic nerves, but acting as any other tumor acts (see 
above); (2) by direct implication of the chiasma or optic 


1 A well-marked case has been recorded by Dr. James Anderson in the 
Ophthalmic Review for May, 1886. 


2G2 


CLINICAL DIVISION. 


tracts in gummatous inflammation ; (3) in rare cases neuri¬ 
tis, ending in atrophy and blindness, occurs in secondary 
syphilis, with head symptoms pointing to meningitis; 
(4) there are few cases of double papillitis in late secondary 
syphilis without either head symptoms or signs of ocular 
disease other than in the disks; these may properly be 
called “ syphilitic optic neuritis.” 

Atrophy of the Optic Disk. 

By this is meant atrophy of the nerve-fibres of the disk 
and of the capillary vessels which feed it. The disk is too 
white ; milk-white, bluish, grayish, or yellowish, in different 
cases. Its color may be quite uniform, or some one part 
may be whiter than another; the stippling of the lamina 


Fig. 100. 


Fig. 101. 



Simple atrophy of disk. Stip¬ 
pling of lamina cribrosa exposed. 
(Wecker.) 


Atrophy of disk from spinal dis¬ 
ease. Lamina cribrosa concealed. 
Vessels normal. (Wecker.) 


cribrosa maybe more visible thgja in health, or on the other 
hand, entirely absent, as if covered or filled up by white 
paint. Figs. 100 and 101. The central retinal vessels 
may be shrunken or of full size, and their course natural 
or too tortuous; both these points bear upon the diagnosis 
of cause and the prognosis. The choroidal boundary may 
be too sharply defined, or, as in Fig. 99, too hazy; it may 
be even and circular, or irregular and notched. The scle- 


































































DISEASES OF THE OPTIC NERVE. 


263 


rotic ring is often seen with unnatural clearness, exposed 
by wasting of the overlying nerve-fibres. Mere pallor of 
the disk, such as we see in extreme general anaemia, must 
not be mistaken for atrophy; the change is then one of 
color only, without unnatural distinctness, loss of trans¬ 
parency, or disturbance of outline. 

Varieties. 1. The nerve-fibres undergo atrophy dur¬ 
ing the absorption and shrinking of the new connective 
tissue formed in severe neuritis (post-papillitic atrophy, p. 
258 ; embolism, p. 246). 

2. When the disk participates secondarily in inflamma¬ 
tion of the retina or choroid it also participates in the suc¬ 
ceeding atrophy. 

3. Atrophy of any part of the optic nerve or chiasma 
from pressure—as by a tumor or by distention of the third 
ventricle in hydrocephalus—from injury, or local inflam¬ 
mation, leads to secondary atrophy, which sooner or later 
reaches the disk. Such cases often show the conditions of 
pure atrophy, without adventitious ^opacity or disturbance 
of outline, and often without change in the retinal vessels. 
They are not very common. 

4. The optic nerves are liable to chronic sclerotic changes, 
with thickening of the connective-tissue framework and 
atrophy of the nerrve-fibres, without the occurrence of papil¬ 
litis, The change in these cases appears often to begin at 
the disk, but the exact order of events in this large and 
important group is not fully known. Groups 3 and 4 fur¬ 
nish the cases which are known clinically as “ primary” 
or 1 ‘ progressive ” atrophy of the optic disk. 

Clinical aspects of atrophy of the disks. As in optic 
neuritis, so in atrophy and pallor of the disk, there is no 
invariable relation between the apj^earance (especially the 
color) of the disk and the patient’s sight. A considerable 
degree of pallor, which it may be impossible to distinguish 
from true atrophy, is sometimes seen with excellent central 


264 


CLINICAL DIVISION. 


vision, though usually accompanied by some defect of the 
visual field. Again, the disks often look alike, although 
the sight is much better in one eye than the other. 


L. Fig. 102. R. 



Irregular contraction of fields of vision in a case of progressive atrophy of 
optic nerves. The loss is symmetrical, but more advanced In the L., where 
it has extended over the fixation point; in the R. it has just reached the fixa¬ 
tion point at one place. The black represents the parts lost. 


Patients with atrophy of the disk come to us because they 

cannot see well, or are quite blind. There are usually no 

« 

Fig. 103. 



Irregular contraction with central loss of L. visual field from progressive 
atrophy of optic nerve in locomotor ataxy. The black represents the blind 
parts ; the shading shows partial loss of vision. 


other local symptoms except such as may be furnished by 
the pupils. In post-papillitic atrophy the pupils are gen¬ 
erally too large and sluggish or motionless to light; in 


DISEASES OF THE OPTIC NERVE. 


265 


most cases of primary progressive atrophy in the early 
stages they are of ordinary size or smaller than usual, and 
act very imperfectly. Chapter XXIII. When only one 
eye is alfected, the other being quite healthy, the pupil of 
the amaurotic eye has no direct action to light and is often 
a little larger than its fellow. 

The visual field in cases of atrophy is generally con¬ 
tracted, or shows irregular invasions or sector-like defects. 
Figs. 102 and 103. Color-blindness is a marked symptom in 
nearly all cases, but is not always proportionate to the loss 
of visual acuteness, being in some much greater and in 
others much less than the state of central vision would lead 
us to suspect. Green is the color lost first in nearly all 
cases, and red next. 

A. Cases in which both disks are atrophied may be con¬ 
veniently classified as follows in regard to diagnosis and 
prognosis. 

1. If the changes point decidedly to recently past papil¬ 
litis, there is some prospect of improvement; but, on the 
other hand, sight may for a time get worse. The case 
must of course be investigated most carefully as to the 
cause of the neuritis. If sight have been stationary for 
some months, further change is unlikely. 

2. If the retinal arteries are much shrunken, whether 
neuritis has occurred or not, the prognosis is bad. 

If we cannot decide after careful examination whether 
papillitis has been present or not, inquiry should be made 
as to former symptoms of intracranial disease; since con¬ 
secutive atrophy cannot always be distinguished from 
primary. But in a large number of those cases which 
present no ophthalmoscopic evidences of previous papillitis 
the history will be quite negative as to cerebral symptoms; 
and these will, for the most part, fall into the two follow¬ 
ing groups: 

3. There are symptoms of chronic disease of the spinal 


26G 


CLINICAL DIVISION. 


cord, usually of locomotor ataxy; or much more rarely 
symptoms of general paralysis of the insane. 

4. No cause can he assigned for the atrophy ; these cases 
are less common than has been supposed. 

The sclerosis leading to atrophy of the disks in locomotor 
ataxy (3) usually comes on early in that disease, often be¬ 
fore well-marked spinal symptoms have appeared. The 
optic atrophy always becomes symmetrical, though it gen¬ 
erally begins some months sooner in one eye than in the 
other; it always progresses, though sometimes not for 
years, to complete, or all but complete, blindness. The 
disks are usually characterized by an uniformly opaque, 
gray-white color, the lamina cribrosa being often concealed, 
although neither the central vessels nor the disk margins 
are obscured in the least. Fig. 101. The central vessels 
are often not materially lessened in size, even when the 
patient is quite blind. 

Cases of progressive atrophy are seen which resemble 
the above, but where no signs of spinal cord disease are 
present, even though the patient has been long blind (4). 
It is known that in some of these patients ataxic symptoms 
come on sooner or later, and it is highly probable that, 
could the cases be followed up for a sufficient number 
of years, this termination would be found to be common j 1 
indeed, pre-ataxic optic atrophy is now a recognized method 
of onset of the disease. Undoubtedly in some cases the 
optic nerve atrophy is not followed by locomotor ataxy, 
but some of the other signs of tabes dorsalis may be present, 
as the Argyll-Robertson pupil or the loss of knee-jerk. 
We should probably be justified in grouping such cases 

1 I have found decided spinal symptoms in 58 of a series of 76 consecutive 
cases of progressive atrophy, and of the remaining 18, several showed one or 
more symptoms which were probably of spinal origin. Peltesohn finds about 
40 per cent, of all cases of non-neuritic progressive optic atrophy in Hirsch- 
berg’s clinic to be associated with spinal or cerebro-spinal disease. Knapp’s 
Arch., xvi. 142. 


DISEASES OF THE OPTIC NERVE. 


267 

under the heading of arrested tabes. Cases of Classes 3 
and 4 are far more common in men than women. In a few 
the atrophy is caused by a tumor compressing the chiasma 
without setting up papillitis. 

In making the prognosis of cases of progressive, uncom¬ 
plicated amblyopia or amaurosis, with more or less atrophy 
of disks, special attention is to be paid to whether the 
failure was synchronous or not, and whether it is now 
equal in the two eyes. The state of the field of vision in 
cases seen early is also of much importance; peripheral 
contraction, as distinguished from central defect, is a bad 
sign, for progressive atrophy seldom begins with defect in 
the centre of the field. In cases of gradual, uncompli¬ 
cated failure of sight, where the symptoms have from the 
beginning been equally symmetrical, the atrophic changes 
are usually but slight in comparison with the defect of 
sight. 

B. Single amaurosis with atrophy of the disk in a majority 
of cases indicates former embolism of the central artery, 
some local affection of the trunk of the optic nerve, “retro- 
ocular neuritis,” or pressure on the nerve by tumor just in 
front of the chiasma. But here it must be remembered 
that in cases of progressive atrophy, accompanying or pre¬ 
ceding spinal disease, a very long interval occasionally 
separates the onset of the disease in the two eyes, 1 and we 
may see the first eye before the commencement of the dis¬ 
ease in the second. 

Blindness of one eye following immediately after a fall 
or blow on the head indicates damage to the nerve from 
fracture of the optic canal, or hemorrhage into the nerve- 
sheath. If the nerve is torn across, visible atrophy of the 
disk sets in in a few weeks. The blow has generally been 
on the front of the head and on the same side as the 

1 This interval may be three or four years, and an interval of from one to 
two years is not very rare. 


268 


CLINICAL DIVISION. 


affected eye. A similar condition follows wound or rup¬ 
ture of the nerve in the orbit, by a thrust, stab, or gun¬ 
shot injury. Laceration of the central retinal vessels 
alone, behind the point at which they enter the nerve, 
is said to cause appearances like those due to embolism 
and thrombosis. In cases of injury to the optic nerve 
improvement is rare. 


CHAPTER XV. 


AMBLYOPIA AND FUNCTIONAL DISORDERS OF SIGHT. 

The term amblyopia means dulness of sight, but its use 
is generally restricted to cases of defective acuteness of 
sight, short of blindness, in which there is little or no 
ophthalmoscopic change. Amaurosis indicates a more 
advanced affection—complete blindness without visible 
changes. These terms, then, refer to the patient’s symp¬ 
toms, while papillitis and atrophy imply changes seen by 
the observer. Amblyopia may depend upon disease in the 
retina in any part of the optic nerve or tract, or in the 
optic centres; and it may be temporary or permanent. 
It is always most important to distinguish single from 
symmetrical cases. 

Two common and important forms of unsymmetrical 
amblyopia may be considered first. 

1. Amblyopia from suppression of image (congenital am¬ 
blyopia). It is well known that many children with con¬ 
vergent squint see badly with the squinting eye; that this 
defect varies in degree, and may be so great that fingers 
can hardly be counted; that, at any rate in the higher 
grades, the defect is chiefly or only present in that part 
of the visual field which is common to both eyes, Fig. 34, 
and is irremediable; while in the lower degrees the defect 
may be more or less removed by separate practice of the 
defective eye. 1 It has been assumed by one school that 
this amblyopia is due to a congenital defect, presumably 
of the visual centre, which determines the incidence of the 

1 Of such improvement I have myself had very little experience. 

( 269 ) 


270 


CLINICAL DIVISION. 


squint, just as defect due to an ulcer of the cornea may 
do. Another view supposes that the child, born with two 
good eyes, but being obliged to squint, owing to hyperme- 
tropia, learns to suppress the consciousness of the image in 
the squinting eye in order to avoid the inconvenience of 
double vision, and that this habit, if begun very early in 
life, causes permanent amblyopia of the eye, due to a de¬ 
fective development of the perceptive faculty in the corre¬ 
sponding centre. For the former view it is urged that no 
one has ever watched the onset of this amblyopia, since it 
is always present at the youngest age when tests can be 
applied; that we meet with cases of unexplained defect of 
one eye without squint; and that this supposed power of 
suppression cannot be learnt in later life, as is shown by 
the permanence of diplopia in all cases of paralytic squint 
acquired after childhood. In favor of the suppression 
theory we may argue that while such defect might be 
acquired early, it could not be expected to come on late, 
after the visual centre in question had been educated ; 
precisely as want of training of the ocular muscles in 
early infancy, from defective sight due to disease, leads 
to incurable nystagmus (Chapter XXI.) much more fre¬ 
quently than do similar defects of sight acquired after the 
muscles have been got into harmonious use; that in many 
of the cases of defect without squint a history of previous 
squint can be obtained and that if the defect were con¬ 
genital it would involve the whole field equally, not only 
that part which is common to the two eyes. In alternating 
concomitant squint, whether convergent or divergent, there 
is no diplopia, although the vision of each eye is as a rule 
equally good ; the patient has the power of instantaneously 
suppressing the consciousness of the image in whichever 
happens to be the squinting eye—a fact in favor, so far 

1 I believe that the spontaneous disappearance of hypermetropic squint, 
which is not uncommon, has received too little attention. 


AMBLYOPIA. 


271 


as it goes, of the suppression theory. On the other hand, 
it is true that in cases of anisometropia great variations 
are encountered in the degree of perfection to which the 
more ametropic eye can be raised by glasses—a fact per¬ 
haps in favor of the congenital amblyopia theory. 

2. Amblyopia from defective retinal images. In cases of 
high hypermetropia or astigmatism, when clear images have 
never been formed, the correction of the optical defect by 
glasses at the earliest practicable age often fails, at any 
rate for a time, to give full acuteness of sight. Want of 
education in the appreciation of clear images is probably 
the chief cause, though defective development of the retina 
may also come into play. We may explain in the same 
way the common cases in which, with anisometropia (Chap¬ 
ter XX.), the sight of the more ametropic eye, even when 
corrected by the proper glasses, remains defective, although 
no squint has ever existed; and in some degree also the 
defect often observed after perfectly successful operations 
for cataract in children. Amblyopia of this kind when 
discovered late in life is seldom altered by correcting the 
optical error, but in children the sight often improves 
when suitable glasses are constantly worn. 

Great defect of one eye from the causes just mentioned, 
or gradual painless failure from disease, often exists un¬ 
known for years, until accidentally discovered by closing 
the sound eye or by trying the sight of each eye separately 
— e. g., in an examination for the army or other public 
service. The patient in such cases is naturally concerned 
at what he thinks is a recent defect, but caution is needed 
in accepting his view, unless he has previously been in the 
habit of “ sighting ” objects with the eye in question, as in 
rifle-shooting. But sudden failure of one eye is, as a rule, 
dated correctly. 

In cases of amblyopia not belonging to the above cate¬ 
gories, a definite date of onset will generally be given. 


272 


CLINICAL DIVISION. 


Two principal divisions may be formed, according as the 
amblyopia affects one eye or both. 

3. Cases of recent failure of one eye with little or no 
ophthalmoscopic change occur rather rarely, and gener¬ 
ally in young adults; the onset is often rapid, with neu¬ 
ralgic pain, sometimes very severe, in the same side of the 
head. There may be pain in moving the eye, or tender¬ 
ness when it is pressed back into the orbit. The degree of 
amblyopia varies much, but is often especially marked at 
the centre of the field. The disk of the affected eye is 
sometimes hazy and congested. The attack is often attri¬ 
buted to exposure to cold. Most of the cases recover under 
the use of blisters and iodide of potassium, but in a certain 
number the defect is permanent, and the disk becomes 
atrophied. Such cases are most probably caused by a 
retro-ocular neuritis, often slight and transient, and the 
cases are perhaps analogous to peripheral paralysis of the 
facial nerve. 

4. Much more common is a progressive and equal failure 
in both eyes, often amounting in a few weeks or months to 
great defect (14 or 20 Jaeger, or V. from ^ to y 1 ^), with 
no other local symptoms except perhaps a little frontal 
headache, but often with nervousness, general want of 
tone, and loss of sleep and appetite. Ophthalmoscopic 
changes, never pronounced, may be quite absent; at an 
early period the disk is often decidedly congested and 
slightly swollen and hazy, but these changes are all so 
ill-marked that competent observers may give different 
accounts of the same case; later, the side of the disk near 
the y. s., and finally in bad cases the whole papilla, become 
pale, and the diagnosis of incomplete atrophy is given. 
The defect of sight is described as a “ mist,” and is usually 
most troublesome in bright light and for distant objects, 
being less apparent early iu the morning and toward even¬ 
ing. The pupils are normal, or at most rather sluggish to 


AMBLYOPIA. 


273 


light. The defect of V. is limited to, or most intense at, 
the central part of the field (central scotoma ), occupying an 
oval patch which extends from the fixation point (corre¬ 
sponding to the y. s.) outward, toward, and often as far as 
the blind spot, corresponding to the optic disk. The affected 
area is also found to be color-blind for red and screen; but 
this loss of color perception being usually incomplete, alike 
in degree and superficial extent. Fig. 104. will often escape 
detection if large color tests be used; while it will readily 
be found by using a small colored spot of from 5 to 15 mm. 


Fig. 104. 



R. right, L. left, visual field in a case of central amblyopia from tobacco ’ 
smoking. The shaded area is the part over which acuteness of vision and 
color perception are lowered, relative central scotoma, no part of the field 
being absolutely blind. The dotted line marked It. shows the boundary of 
the field for red (see Fig. 33). 


square. The patient, closing one eye, “ fixes” the finger 
or nose of the observer, who then removes the colored spot 
from the fixation point in various directions toward the 
periphery; the color, instead of appearing brightest at the 
centre of the field, will be dull or unrecognizable there, 
becoming brighter and easily recognized toward the periph¬ 
ery. There is no contraction of the field, and thus, since 
surrounding objects are seen as well as ever, and the 
patient has no difficulty in going about, his manner differs 
from that of one with progressive atrophy, who finds diffi- 

18 






274 


CLINICAL DIVISION. 


culty in guiding himself, because his visual field is con¬ 
tracted. 

The patients are almost without exception males, and at 
or beyond middle life. With very rare exceptions they are 
smokers, and have smoked for many years, and a large 
number are also intemperate in alcohol. The exceptions 
occur chiefly in a very few patients in whom a similar kind 
of amblyopia is hereditary, is liable to affect the female as 
well as the male members, and may come on much earlier 
in life. The etiology of such cases is obscure, and in some 
few of them there is no evidence of heredity. 

In the common cases it is now generally agreed that 
tobacco has a large share in the causation, and in the 
opinion of a number of observers it is the sole excitant. 
The direct influence of alcohol, and of the various causes 
of general exhaustion, such as anxiety, underfeeding, and 
general dissipation, is still to some extent an open ques¬ 
tion. See Chapter XXIII., Diabetes. My own opinion, 
based on the examination of a large number of cases, is 
that tobacco is the essential agent, and that the disuse or 
greatly diminished use of tobacco is the one essential 
measure of treatment. It is important to remember that 
the disease may come on when either the quantity or the 
strength of the tobacco is increased, or when the health 
fails and a quantity which was formerly well borne becomes 
excessive. Hence cases of double central amblyopia may, 
as a rule, except in the rare form above mentioned, be 
named tobacco amblyopia. The symmetry of tobacco am¬ 
blyopia is not always precise, and it appears, in very rare 
cases, to be delayed. 1 

The prognosis is good if the patient come early, and if 
the failure have been comparatively quick. In such cases 
really perfect recovery may occur, and very great improve- 

1 J. Hutchinson, Jr.: Ophthalmic Hospital Reports, xi. 1S86. 


AMBLYOPIA. 


275 


ment is the rule. In the more chronic cases, or cases 
where already the whole disk is pale, a moderate improve¬ 
ment, or even an arrest of progress, is all we can expect. 
If smoking be persisted in, no improvement takes place, 
and the amblyopia increases up to a certain point; but 
complete blindness very seldom if ever occurs. In the 
treatment, disuse of tobacco is the one thing essential. 
Relapse sometimes occurs if smoking be resumed. Drink 
should, of course, be moderated. It is usual to give strych¬ 
nia, subcutaneously or by mouth, for a considerable period, 
but whether any medicine acts otherwise than by improv¬ 
ing the general tone is doubtful; subcutaneous injections 
of strychnia, carefully carried out, have not given definite 
results in my own cases. Others believe that the constant 
current is useful. There is reason to believe that the dis¬ 
ease depends on a chronic inflammation of the central 
bundles of the optic nerve, beginning at, or a short dis¬ 
tance behind, the eye. 1 

Hemianopia, usually called hemiopia, denotes loss of half 
the field of vision. When uniocular the defect is seldom 
quite regular, and generally depends upon detachment of 
the retina or a very large retinal hemorrhage. It is usu¬ 
ally binocular, and then indicates disease at or behind the 
optic cliiasma. In the great majority of cases the R. or 
L. lateral half of each field is lost. Sometimes only a 
quarter of each field is lost. The line of separation be¬ 
tween the blind and seeing halves is usually sharply de¬ 
fined and nearly straight, only deviating a degree or two 
at the fixation point, so as just to leave central vision in¬ 
tact over an area about corresponding to the fovea cen¬ 
tralis. Fig. 105. In other cases the separating line is 
undulating, and a comparatively large central area of the 
field remains intact. The boundary between sight and 


1 Transactions Ophthalmic Society, vol. i. p. 124, and iii. p. 160. 


276 


CLINICAL DIVISION. 


blindness in hemianopia, though usually abrupt, is some¬ 
times gradual. The retention of central vision over a 
considerable central area has been explained on the 
assumption that the y. s. area receives nerve-fibres from 
both optic tracts, and Bunge and others have lately found 
microscopical evidence that such is really the case; in 
cases like Fig. 105 the apparent deviation of the dividing 
line may perhaps be explained by the difficulty which the 


Fig. 105. 



Fields of vision in a case of L. homonymous lateral hemianopia. The 
dividing line comes within one or two degrees of the fixation point (shown 
by the central dot) in each eye. The lesion causing this hemianopia is 
probably in the optic tract, or not higher than the corpora geniculata. 

patient has in keeping the eye perfectly fixed when the 
test object comes close to the centre. Loss of the R. half 
of each field , meaning loss of function of the L. half of 
each retina, points to disease of the L. optic tract 1 or its 
continuations, or of some part of the L. occipital lobe or 
angular gyrus. The hemiopic pupillary reaction (Wer¬ 
nicke) assists us in localizing the disease. If, when light is 
thrown on the blind half of the retina, the pupil contracts 
as well as when it is thrown on the seeing half in the two 
eyes, the lesion is in the cortex ; but if it does not contract, 
the lesion is in the optic tract. Loss of the two nasal halves 

1 Because the L. optic tract consists chiefly of fibres which supply most of 
the L. half of each retina, those of them destined for the R. eye crossing 
over at the optic commissure. 


AMBLYOPIA. 


277 


is extremely rare. Loss of the two temporal halves (tem¬ 
poral hemianopia) points to disease at the anterior part of 
the chiasma. Even when hemianopia has lasted for years 
the optic disks seldom show any change. When the lateral 
hemianopia co-exists with hemiplegia the loss of sight is on 
the paralyzed side; “the patient cannot see to his par¬ 
alyzed side” (Hughlings Jackson). If double hemiopia 
occurs, the patient is totally blind in both eyes. Another 
less common affection of sight, crossed amblyopia, is be¬ 
lieved to be due to a lesion of a higher centre in the angu¬ 
lar gyrus which presides in some degree over the whole of 
both fields of vision, but chiefly over that of the opposite 
eye. A unilateral lesion of this kind produces amblyopia 
with great contraction of the field of the opposite eye, 
and with some contraction of the field of the eye of the 
same side. The symptoms are much like those of hyster¬ 
ical amblyopia in one eye. If such a lesion were double, 
it would presumably produce a high degree of amblyopia, 
with contraction of the fields in both eyes, the activity of 
the pupils being retained. A few cases of hemianopia for 
colors alone have been recorded. 1 

Hysterical amblyopia and amaurosis take various forms, 
and real defect may be mixed up with feigning. In hys¬ 
terical hemianaesthesia the eye on the affected side is some¬ 
times defective or quite blind. In other cases of hysteria 
both sides are defective, but one worse than the other; 
there is concentric contraction of the visual fields, some¬ 
times with, sometimes without, color-blindness, a varying 
degree of defective visual acuteness, and sight is often dis¬ 
proportionately bad by feeble light, hence the term “ anaes¬ 
thesia of the retina” is sometimes used. There may, 
however, be in addition irritative symptoms—watering, 
photophobia, and spasm of accommodation, and then the 

1 See exhaustive paper by Mackay : British Medical Journal, November 10, 
1888. 


278 


CLINICAL DIVISION 


term “ hypersesthesia retinre” or “ oculi ” seems more ap¬ 
propriate. Amblyopia with the above characters has been 
known to follow a blow upon the eye affected which was 
so slight as not to cause the least ophthalmoscopic change; 
again, when one eye has been suddenly lost by wound or 
embolism a condition indistinguishable from hysterical 
blindness may rapidly come on in the other (compare sym¬ 
pathetic irritation). It is important to note that in hyster¬ 
ical amblyopia, even of high degree and long standing, the 
reflex action of the pupil, direct as well as indirect, is fully 
preserved, and the ophthalmoscopic appearances are quite 
normal. The prognosis is nearly always good, though 
recovery is sometimes slow, and relapses may occur. In 
some of the worst cases I have seen there has been consid¬ 
erable ametropia. 

True hysterical amblyopia seems allied, from the ophthal¬ 
mic standpoint, with a much larger and more important 
class, best epitomized by the term asthenopia , in which 
photophobia, irritability, and want of endurance of the 
ciliary muscle, accommodative asthenopia , or sometimes of 
the internal recti, muscular asthenopia, with some conjunc¬ 
tival irritability, are the main symptoms, acuteness of sight 
being usually perfect, and the refraction nearly or quite 
normal. Of the retinal, conjunctival, and muscular fac¬ 
tors, any one may be more marked than the others, and it 
would seem that, given a certain state of the nervous sys¬ 
tem, which may be described as impressionable, or hyper- 
aesthetic, over-stimulation of any one is liable to set up 
an over-sensitive state of the other two. These patients 
often complain also of dazzling pain at the back of the 
eyes, and headache or neuralgia in the head. All the 
symptoms are worse after the day’s work, and sometimes 
on first waking in the morning, and they are liable to 
vary much with the health. Artificial light always aggra¬ 
vates them, because it is often flickering and insufficient, 


AMBLYOPIA. 


279 


but especially because it is hot. The symptoms often lasts 
for months or years, causing great discomfort and serious 
loss of time. 

Causation. The patients are seldom children or old 
people. Most are women, either young or not much past 
middle life, often very excitable, and often with feeble 
circulation. If men, they are emotional, fussy, and often 
hypochondriacal. Some cause, such as prolonged and in¬ 
tense application at needlework or reading, can often be 
traced, and in such cases the symptoms may come on so 
suddenly that the patient becomes within a few hours, or 
a day or two, quite incapacitated for reading. Sometimes 
bright colors, glittering things, or exposure to kitchen fire 
seems specially injurious. Or, again, there is a history of 
phlyctenular ophthalmia or superficial ulcers, which have 
left the fifth nerve permanently unstable. Accommoda¬ 
tive asthenopia with hypermetropia or astigmatism is at 
the bottom of nearly all the cases in which vision is sup¬ 
posed to have been injured by railway and other accidents ; 
the lowered tone caused by the shock is often more appa¬ 
rent in the ciliary muscle, because this muscle is in almost 
constant action and has no substitute. 

Treatment. The refraction and the state of the inter¬ 
nal recti should always be carefully tested, and any error 
corrected by lenses, which may often be combined with 
prisms, with their bases toward the nose. Plain colored 
glasses are sometimes useful. But glasses will not cure the 
disease, and we must not promise too much from their use. 
The patient may be assured that there is no ground for 
alarm, and that the symptoms will probably pass off sooner 
or later. He should be discouraged from thinking about 
his eyes, and he need seldom be quite idle. The artificial 
light used should be sufficient and steady (not flickering), 
and should be shaded to prevent the heat and light from 
striking directly on the eyes. Bathing the eyes freely 




280 


CLINICAL DIVISION. 


with cold water, and the occasional employment of weak 
astringent lotions, are useful, and cold air often acts bene¬ 
ficially. The eyes are often much better after a rest of a 
day or two. Outdoor exercise, and only moderate use of 
the eyes, therefore, should be enjoined. General measures 
must be taken according to the indications, especially in 
reference to any ovarian, uterine, or digestive troubles, or 
to sexual exhaustion in men. 

Functional Diseases of the Retina. 

Functional night-blindness (endemic nyctalopia ) 1 is caused 
by temporary exhaustion of the retinal sensibility from pro¬ 
longed exposure to diffused bright light. The circumstances 
under which it occurs usually imply not only great expo¬ 
sure to bright light, but lowered general nutrition, and 
probably some particular defect in diet. It often co-exists 
with scurvy. Sleeping with the face exposed to bright 
moonlight is believed to bring it on. It is most common in 
sailors after long tropical voyages under bad conditions, 
and in soldiers after long marching in bright sun. In 
some countries it prevails every year in Lent when no 
meat is eaten, and again in harvest-time. It is now but 
rarely endemic in our country, but scattered cases occur 
in springtime, especially in children, and it still occasion¬ 
ally prevails in large schools. 

In this malady two little dry films, consisting of fatty or 
sebaceous matter and epithelial scales, often form on the 
conjunctiva at the inner and outer border of the cornea. 
Their meaning is obscure. A micro-organism, the bacillus 
xerosis , has been described as peculiar to this affection, 


1 Some confusion has arisen as to the use of the words nyctalopia and hemer¬ 
alopia; they are used by Continental writers and those who follow them in a 
sense directly opposed to the common English use of them. It is better, 
therefore, to discard them for their English equivalents, night-blindness and 
day-blindness. 


FUNCTIONAL DISEASES OF THE RETINA. 281 


growing in the conjunctival film; its presence seems to be 
accidental. There are no ophthalmoscopic changes. This 
night-blindness is soon cured by protection from bright 
light and improvement of nutrition, and especially by 
cod-liver oil. That the affection is local in the eye is 
shown by the fact that darkening one eye with a ban¬ 
dage during the day has been found to restore its sight 
enough for the ensuing night’s watch on board ship, the 
unprotected eye remaining as bad as ever. 

Day-blindness (hemeralopia) occurs in certain cases of 
congenital amblyopia. 

Colored vision is sometimes complained of, and red is the 
color usually noticed. Red vision (erythropsia.) is most 
common some time after extraction of senile cataract, and 
is associated with fatigue; everything looks rosy-red, “ as 
if there was a most beautiful sunset,” as one patient said. 
Overworked, anxious, neurotic children sometimes com¬ 
plain that after reading or sewing “everything turns red,” 
or “ red and blue.” I have not heard green or yellow men¬ 
tioned. It has also been seen in women much exhausted 
by fasting. 

Micropsia. Patients sometimes complain that objects 
look too small. When not due to insufficiency of accom¬ 
modative power it is generally a symptom of disease of 
the outer layers of the retina, especially in the central 
region, and syphilitic retinitis is the most common cause. 
Both micropsia and its opposite, megalopsia, are sometimes 
seen in hysterical amblyopia. 

By muscse volitantes are understood small dots, rings, 
threads, etc., which move about in the field of vision, but 
do not actually cross the fixation point, and never inter¬ 
fere with sight. They are most easily seen against the 
sky, or a bright background, such as the microscope field. 
They depend upon minute changes in the vitreous, which 
are present in nearly all eyes, though in much greater 


282 


CLINICAL DIVISION. 


quantity in some than others. They vary, or seem to 
vary, greatly with the health and state of the circulation, 
but are of no real importance. They are most abundant 
and troublesome in myopic eyes. 

Diplopia. See Chapter XXI.; also pp. 379 and 198 for 
Uniocular Diplopia. 

For affections of sight in Megrim and Heart Disease, 
see Chapter XXII. 

Malingering. Patients now and then pretend defect or 
blindness of one or both eyes, or exaggerate an existing 
defect, or sometimes secretly use atropine in order to dim 
the sight. The imposture is generally evident enough 
from other circumstances, but detection is occasionally 
very difficult. Malingering and intentional injuries of 
the eye are very rare here, but common in countries where 
the conscription is in force. 

The pretended defect of sight is usually confined to one 
eye. If the patient be in reality using both eyes, a prism 
held before one, by preference “ the blind” one, will 
produce double vision. The stereoscope, and also colored 
glasses, may be made very useful in detecting imposture. 
Another test, when only moderate defect is asserted, is to 
try the eye with various weak glasses, and note whether 
the replies are consistent; very probably a flat glass or a 
weak concave may be said to “ improve” or “ magnify” 
very much. Again, atropine may be put into the sound 
eye, and when it has fully acted the patient be asked to 
read small print; if he reads easily with both eyes open, 
the imposture is clear, for he must be reading with the 
so-called “blind” eye. If absolute blindness of one eye 
be asserted, the state of the pupil will be of much help, 
unless the patient have used atropine; for if its direct 
reflex action be good, the retina and nerve cannot be 
much diseased, but as to this point compare Hysterical 
Amblyopia, p. 277. 


FUNCTIONAL DISEASES OF THE RETINA. 983 


Pretended defect of both eyes is more difficult to expose, 
and, indeed, it may be impossible to absolutely convict the 
patient if he be intelligent and instructed. The state of 
the pupils, of the visual fields, and of color perception are 
among the best tests. 

Priestley Smith has recently suggested the use of a prism 
which the malingerer will involuntarily overcome by moving 
the eye before which it is placed, alternately holding the 
prism before the eye, and removing it. If there is good 
vision, the eye will be seen to move back and forth to avoid 
diplopia, which the prism would otherwise cause. If the 
eye be really blind, no such movement will occur. 

Color-blindness may be congenital or acquired. When 
acquired it is symptomatic of disease of the optic nerve, or, 
as for example in hysterical amblyopia, of some affection 
of the visual centre. 

Congenital color-blindness is not often found unless 
looked for. According to recent and extended researches 
in various countries, a proportion varying from about 3 to 
5 per cent, of the males are color-blind in greater or less 
degree, and it appears to be more common in the lower 
than in the upper classes. These facts show the impor¬ 
tance of carefully testing all men whose employment ren¬ 
ders good perception of color indispensable, such as railway 
signalmen and sailors. Color-blindness is usually partial 
— i. e., for only one color or one pair of complimentary 
colors, but is occasionally total. The most common form 
is that in which pure green is confused with various shades 
of gray and of red (red-green blindness); blindness for 
blue and yellow is very rare. The blindness may be in¬ 
complete, perception of very pale or very dark red or green 
— e. g., being enfeebled, while bright red and green are 
well recognized ; or it may be complete for all shades and 
tints of those colors. Congenital color-blindness is very 
often hereditary, but nothing further is known of its cause. 


284 


CLINICAL DIVISION. 


It is very rare in women (0.2 per cent.). The acuteness of 
vision— i. e., perception of form—is normal. Both eyes 
are affected. 1 

The detection of color-blindness, either congenital or 
acquired, is easy if, in making the examination, we bear 
in mind the two points already referred to at p. 57, viz.: 
(1) Many persons with perfect color perception know very 
little of the names of colors, and appear color-blind if asked 
to name them; (2) the really color-blind often do not 
know of their defect, having learned to compensate for it 
by attention to differences of shade and texture. Thus a 
signalman may be color-blind for red and green; yet he 
may, as a rule, correctly distinguish the green from the 
red light, because one appears to him “brighter” than 
the other. The quickest and best way of avoiding these 
sources of error has been mentioned at p. 57. A certain 
standard color is given to the patient without being named, 
and he is asked to choose from the whole mass of skeins of 
wool all that appear to him of nearly the same color and 
shade—no two being really quite alike. If, for example, 
he cannot distinguish green from red, he will place the 
green test-skein side by side with various shades of gray 
and red. Wilful concealment of color-blindness is im¬ 
possible under this test if a sufficient number of shades be 
used. 

As it is necessary to detect slight as well as high degrees, 
the first or preliminary test should consist of very pale 
colors, and a pale pure green is to be taken as the test No. 

1 (see plate in the Appendix); Nos. 1 to 5 are liable to 
be confused with this color. For ascertaining whether 
the defect be of high degree or not, stronger colors are 
then used; a bright rose color— e. g., II. a, may be con¬ 
fused with blue, purple, green, or gray of corresponding 


1 But on this point further research is needed. 



FUNCTIONAL DISEASES OF THE RETINA . 285 


depth (Nos. 6 to 9); and a scarlet, II. b, with various 
shades and tints of brown and green (Nos. 10 to 13). 

It may here be noted that the visual field is not of the 
same size for all colors, Fig. 33, green and red having the 
smallest fields, and that the perception of all colors is, like 
perception of form, sharpest at the centre of the field. 
With diminished illumination some colors are less easily 
perceived than others, red being the first to disappear, and 
the blue persisting longest— i. e.., being perceived under 
the lowest illumination; but in dull light the colors are 
not confused, as in true color-blindness. In congenital 
color-blindness, as we have seen, red-green blindness is the 
most common form; and in cases of amblyopia from com¬ 
mencing atrophy of the optic nerve, green and red are 
almost always the first colors to fail, blue remaining last. 


/ 


1 


CHAPTER XVI. 

DISEASES OF THE VITREOUS. 

The vitreous humor is nourished by the vessels of the 
ciliary body, retina, and optic disk, and is probably influ¬ 
enced by the state of the choroid also; and in most cases 
disease of the vitreous is associated with, and dependent 
on, disease of one or other of the structures named. 

Thus, in connection with the various surrounding mor¬ 
bid processes, the vitreous maybe the seat of inflammation, 
acute or chronic, general or local., and of hemorrhage. It 
may also degenerate, especially in old age; its cells and 
solid parts, undergoing fatty change, become visible as 
opacities, while its general bulk becomes too fluid. The 
only alteration that we can directly prove in the vitreous 
during life is loss of transparency from the presence of 
opacities moving or more rarely fixed in it, but accord¬ 
ing as such opacities move quickly or slowly we infer that 
the humor itself is, or is not, more fluid than in health. 

Opacities in the vitreous may take the form of large, 
dense masses, or of membranes like muslin, crape, “ bees’ 
wings ” of wine, bands, knotted strings, or isolated dots; 
and they may be either recent, or the remains of long ante¬ 
cedent exudation, hemorrhage, or degeneration, or newly- 
formed bloodvessels. Again, the vitreous may become 
uniformly misty, owing to the diffusion of numberless 
dots, “dust-like” opacities, which need careful focussing 
by direct examination with a convex lens (about -J- 12 D.) 
behind the mirror, to be separately seen. 

Opacities in the vitreous are usually detected, with great 
( 286 ) 


DISEASES OF THE VITREOUS. 


ease, by direct ophthalmoscopic examination at about 12" 
from the patient, but are generally situated too far forward 
— i. e., too far within the focus of the lens system—to be 
seen clearly at a very short distance without a -{- lens be¬ 
hind the mirror. If the patient move his eye sharply and 
freely from side to side and from above downward, the 
opacities will be seen against the red ground, as dark fig¬ 
ures which continue to move after the eye has come to rest; 
they are thus at once distinguished from opacities in the 
cornea or lens, or from dimly seen spots of pigment at the 
fundus, which stop when the eye stops. The opacities in 
the vitreous move, just as solid particles and film move in 
a bottle after the bottle has been shaken; the quickness 
and freedom of their movement in the one case as in the 
other depending very much on the consistence of the fluid. 
When the opacities pass across the field quickly and make 
wide movements, we may be sure that there is synchysis or 
fluidity of the vitreous humor; if they move very lazily, 
its consistence is probably normal; if only one or two 
opacities be present they may only come into view now 
and then. Moving opacities in the vitreous obscure the 
fundus both to the direct and indirect ophthalmoscopic 
examination, in proportion to their size, density, and posi¬ 
tion ; a few isolated dots scarcely affect the brightness of 
the ophthalmoscopic image. 

The opacities may lie quite in the cortex of the vitreous 
and be anchored at the fundus, so as to have but little 
movement. Such opacities, generally single, are found 
lying over or near to the disk, and may be the result either 
of inflammation or of hemorrhage; they are often mem¬ 
branous, more rarely globular, and not perfectly opaque. 
Such an opacity should be suspected when, by indirect 
ophthalmoscopic examination, a localized haze or blurring 
of some part of the disk or its neighborhood is noticed. 
The opacity must then be searched for by the direct 


288 


CLINICAL DIVISION. 


method, the patient’s eye being at rest; by altering the 
distance from the patient, or by turning on various con¬ 
vex lenses (or concave, if the eye be very highly myopic) 
the opacity will come sharply into view. The patient’s 
refraction must be approximately known in order to make 
this examination properly. Densely opaque white mem¬ 
branes may also form over the disk or upon the retina, the 
nature and situation of which are diagnosed in the same 
way. 

Diffused haziness of the vitreous causes a corresponding 
degree of dimness of outline and darkening of the details 
of the fundus, as if these were seen through a thin smoke. 
The disk, in particular, appears red, without really being 
so. Much the same appearances are caused by diffused 
haze of the cornea or lens, but the presence of these changes 
will, of course, have been excluded by focal illumination. 
There are even cases of vitreous disease where no details 
can be seen, even by careful examination, though plenty 
of light reaches and returns from the fundus. In these 
the light is scattered by innumerable little particles, each 
of which is transparent, so that the light, without being 
absorbed, is distorted and broken up, as in passing through 
ground-glass or white fog, or a partial mixture of fluids of 
different densities, such as glycerin and water. This fine 
general haze is found chiefly in syphilitic choroido-retinitis, 
in which infiltration of the vitreous with cells is known to 
occur. It is not always easy, nor indeed possible, to distin¬ 
guish with certainty between diffuse haze of the vitreous 
and diffuse haze of the retina. 

Crystals of cholesterin sometimes form in a fluid vitreous, 
and are seen with bright illumination as minute, dancing, 
golden spangles, when the eye moves about, sparkling syn- 
chysis. They proportionately obscure the fundus. Large 
opacities just behind the lens may be seen by focal light in 
their natural colors. In rare cases of choroido-retinitis, 


DISEASES OF T1IE VITREOUS. 


289 

minute growths, consisting chiefly of bloodvessels, form 
on the retina, and project into the vitreous; they are 
rather curiosities than of practical importance. 

Parasites (cysticercus cellulosae) occasionally come to 
rest in the eye, and in development penetrate into the 
vitreous; they are rarely seen in England, but are com¬ 
paratively common in some parts of Germany. Very 
rarely a foreign body may be visible in the vitreous. 

The following are the conditions in which disease of the 
vitreous is most commonly found : 

1. Myopia of high degree and old standing; the opaci¬ 
ties move very freely, showing fluidity of the humor, and 
are sharply defined. They are often the result of former 
hemorrhage. 

2. After severe blows, causing hemorrhage from the ves¬ 
sels of the choroid or ciliary body. When recent and 
situated near the back of the lens the blood can often be 
seen by focal light; if very abundant it so darkens the 
interior of the eye that nothing whatever can be seen with 
the mirror. 

3. After perforating wounds. The opacity will be blood 
if the case be quite recent. Lymph or pus in the vitreous 
gives a yellow or greenish-yellow color, easily seen by focal 
light, or even by daylight, and usually most dense toward 
the position of the wound. 

4. In rare cases large hemorrhages into the vitreous 
occur spontaneously in healthy eyes, with hemorrhages 
into the retina (not to be confused with retinitis lnemor- 
rhagica, p. 244). Relapses often occur, and detachment 
of retina may ensue. The subjects are generally young 
adult males liable to epistaxis, constipation, and irregu¬ 
larity of circulation (Eales); gout may have some influ¬ 
ence (Hutchinson). This affection seems sometimes to be 
related to the form of choroiditis referred to at p. 227. 

In all of the above cases detachment of the retina is 


19 


290 


CLTNICAL DIVISION. 


likely to occur sooner or later, and if both be present, the 
differential diagnosis may be difficult. 

5. Syphilitic choroiditis and retinitis. There is often 
diffuse haze, in addition to large, slowly floating opacities. 
The change here is due to inflammation, and the opacities 
may entirely disappear under treatment. These are the 
cases in which new vessels in the vitreous are most common. 

6. Some cases of cyclitis and cyclo-iritis. The opacities 
are inflammatory. 

7. In the early stage of sympathetic ophthalmitis. The 
opacities are inflammatory. 

8. In various cases of old disease of choroid, usually in 
old persons, and without proof of syphilis. No doubt many 
of these indicate former choroidal hemorrhages. 

9. Cases occur in which no cause, either local or general, 
can be assigned for the presence of opacities in the vitreous. 




/ 


CHAPTER XVII. 


GLAUCOMA. 

In this peculiar and very serious disease the character¬ 
istic objective symptom is increased tightness of the eye- 
capsule, sclerotic and cornea, “increased tension;” all 
the characteristic features of the disease depend upon this. 
The disease is much more common after middle life, when 
the sclerotic becomes less distensible than before; and it 
is more common in hypermetropic eyes, where the sclerotic 
is thick, than in myopic eyes, where it is thinned by elon¬ 
gation of the globe. 

Glaucoma may be primary, coming on in an eye appar¬ 
ently healthy, or the subject of some disease, such as senile 
cataract, which has no influence on the glaucoma; or it 
may be secondary, caused by some still active disease of 
the eye, or by conditions left after some previous disease, 
such as iritis. It is always important and seldom difficult 
to distinguish between primary and secondary glaucoma. 

Glaucoma differs in severity and rate of progress from 
the most acute to the most chronic and insidious form ; but 
in every form it is a progressive disease, and unless checked 
by treatment goes on to permanent blindness. The disease 
is very often symmetrical, attacking the second eye after a 
varying interval. 

It is customary and useful to speak of glaucoma as either 
acute, subacute, or chronic. But many intermediate forms 
are found, and the same eye may, at different stages in its 
history, pass through each of the three conditions. We 
may, indeed, here observe that acute and subacute out- 

( 291 ) 


292 


CLINICAL DIVISION. 


bursts are generally preceded by a so-called “ premonitory ” 
stage, in which, the symptoms are not only chronic and 
mild, but remittent; the intervals of remission becoming 
shorter and shorter, till at length the attacks become con¬ 
tinuous, and the glaucomatous state is fully established. 
Rapid increase of presbyopia (Chapter XX.), shown by the 
need for a frequent change of spectacles, is a common pre¬ 
monitory sign, though it is often overlooked. 

Chronic glaucoma sets in with a cloudiness of sight, or 
“ fog,” varying in density and often clearing off entirely 
for days or even weeks, “ premonitory stage.” But in 
some cases the failure progresses without remissions from 
first to last. During the attacks of “ fog,” artificial lights 
are seen surrounded by colored rings, “rainbows” or 
“ halos,” due to haze of the cornea, which are to be dis¬ 
tinguished from those due to mucus on the cornea. The 
attacks of fog are often noticed only after long use of the 
eyes, as in the evening or when exhausted, the sight being 
better in the early part of the day and after food. Even 
when the sight has become permanently cloudy, complete 
recovery no longer occurring between the attacks, varia¬ 
tions of sight still form a marked feature. There is no 
congestion, and neuralgic pain, though not uncommon, is 
often entirely wanting. The disease has to be distin¬ 
guished from incipient nuclear cataract, disease of the 
optic nerve, syphilitic retinitis, and attacks of megrim. 

If we see the patient during one of the brief early fits of 
cloudy sight, or after the fog has settled down permanently, 
the following changes will be found: a greater or less de¬ 
fect of sight, not remedied by glasses, is present in one eye, 
or if in both, more in one than the other; the pupil is a 
little larger and less active than normal; the anterior 
chamber may be shallow, and there is usually slight dul- 
ness of the eve from steaminess of cornea, or haze of the 
aqueous humor, and some engorgement of the large per- 


GLA UCOMA. 


293 


forating vessels situated at a little distance from the cornea, 
Figs. 23 and 25 ; the tension is somewhat increased, usu¬ 
ally about —(— 1, p. 46 ; and the field of vision may be con¬ 
tracted, especially on the nasal side. The optic disk will 
be found normal, pale, or sometimes congested in early 
cases; pale and cupped all over at a later stage. There 
may be spontaneous pulsation of all the vessels on the 
disk; or the arteries, if not pulsating spontaneously, will 
do so on very slight pressure on the eyeball. If the case 
be of old standing, the tension will often be much increased, 
the pupil dilated and sluggish, though not motionless, the 
lens hazy, the field of vision much contracted, Fig. 106, 
acuteness of vision extremely defective, the cornea in some 
cases clear, in others dull. In nearly all cases of glaucoma 
the temporal part of the field, nasal part of the retina, re¬ 
tains its function longest; and in advanced cases the patient 
will often show this by his manner or statements ; occasion¬ 
ally the field becomes extremely contracted before central 
vision fails. In some few cases of simple glaucoma scoto¬ 
mata appear at the central parts of the field without con¬ 
traction. 

An eye in which the above symptoms have set in may 
progress to total blindness in the course of months or 
several years without a single ‘‘inflammatory” symptom, 
without either pain or redness —chronic painless glaucoma 
(simple glaucoma ) ; and since the lens often becomes par¬ 
tially opaque and of a grayish or greenish hue, cases of 
chronic glaucoma are sometimes mistaken for senile cata¬ 
ract. 

But more commonly, in the course of a chronic case, 
periods of pain and congestion occur, with more rapid 
failure of sight; or the disease sets in with “inflamma¬ 
tory ” symptoms at once. In these cases of subacute glau¬ 
coma, besides the symptoms named above, we find dusky, 
reticulated congestion of the small and large episcleral 


2 L J4 


CLINICAL DIVISION. 


vessels in the ciliary region, Fig. 25, with pain referred 
to the eye, the side of the head, or of the nose, and rapid 
failure of sight. The increase of tension, steaminess, and 
partial anaesthesia of the cornea, the enlarged and sluggish 
pupil, and the shallowness of the anterior chamber, are all 
more marked than is usual in chronic cases, and the media 
are too hazy to allow a good ophthalmoscopic examination. 


Fig. 106. 



Irregular contraction of R. and L. fields of vision in chronic glaucoma; 
from two different cases. The black parts show complete loss ; the shaded 
area shows partial loss. Each field remains best in the outer part. Compare 
with Figs. 102 and 103. 

These symptoms, ending after a few weeks or months in 
complete blindness, may remain at about the same height 
for months after that event, with slight variations, the eye 
gradually settling down into a permanent state of severe, 
but chronic, non-inflammatory glaucomatous tension. Short 
attacks of subacute glaucoma, with intervals of perfect 
recovery, sometimes occur, remittent glaucoma; permanent 
glaucoma usually supervenes. 

Acute glaucoma (inflammatory or congestive glaucoma) 
differs from the other forms only in suddenness of onset, 
rapidity of loss of sight, and severity of congestion and 
pain. The congestion, both arterial and venous, is in¬ 
tense; in extreme cases the lids and conjunctiva are 
swollen, and there is photophobia, so that the case may 







GLA UCOMA. 


295 


be mistaken for an acute ophthalmia. All the specific 
signs of glaucoma are intensified ; the pupil considerably 
dilated and motionless to light, the cornea very steamy, 
the anterior chamber very shallow, and tension -f- 2 or 3. 
Sight will fall in a day or two down to the power of only 
counting fingers, or to mere perception of light, and if the 
case have lasted a week or two, even p. 1. is usually abol¬ 
ished. The pain is very severe in the eye, temple, back 
of the head, and down the nose; not infrequently it is so 
bad as to cause vomiting, and many a case has been mis¬ 
taken for a “ bilious attack ” with a “ cold in the eye,” for 
“ neuralgia in the head,” or “ rheumatic ophthalmia.” 
Some cases, however, though very acute, are mild and re¬ 
mit spontaneously; but these, like the ones mentioned in 
the preceding paragraph, often pass on into the severe type 
now described. 

Absolute glaucoma is glaucoma that has gone on to per¬ 
manent blindness. Such an eye continues to display the 
tension and other signs of the disease, and remains liable 
to attacks of pain and congestion for varying periods, but 
in many “absolute” cases, especially when the original 
attack has been acute, changes occur sooner or later, lead¬ 
ing to staphylomata, cataract, atrophy of iris, and finally 
to softening and shrinking of the globe. 

As a rule glaucoma runs the same course in the second 
eye as in the first, but sometimes it will be chronic in one 
and acute or subacute in the other. 

Explanation of the symptoms. The causes which 
produce the temporary attacks or “ premonitory symp¬ 
toms ” lead, if continued, to atrophy of the inner layers 
of the retina and of the disk, and to consequent blindness. 
The increase of tension damages the retina both by direct 
compression and by impeding its circulation, the latter 
being probably the more important factor in the early 
stages. If the media be clear enough to allow a good 


296 


CLINICAL DIVISION. 


view, the retinal arteries are seen to be narrow, and often 
pulsating spontaneously, and the veins engorged. The 
periphery of the retina suffers first and most often 
from this lowering of arterial blood-supply, and hence 
probably the contraction of the visual field; but the inner 
layers of the retina, over its whole extent, suffer if the 
pressure be kept up (1) from this same insufficiency of 
arterial blood, and the changes, including hemorrhage, 
which follow impeded venous outflow; (2) from direct 
compression of the retina; (3) from stretching and atrophy 


Fjg. 107. 



Section of very deep glaucoma cup. Compare Fig. 40. 


of the nerve-fibres on the disk. The floor of the disk, 
lamina cribrosa, being the weakest part of the eye-capsule, 
is slowly pressed backward, the nerve-fibres being dragged 
down, displaced, and finally atrophied ; the direct pressure 
on the nerve-fibres, as they bend over the edge of the disk, 
helps in the same process. Hence finally the disk becomes 
not only atrophied, but hollowed out, Fig. 107, into the well- 
known “ glaucomatous cup.” This cup, when deep, has an 
overhanging edge, because the border of the disk is smaller 
at the level of the choroid than at the level of the lamina 
cribrosa; its sides are quite steep even when the cup is 
shallow, Fig. 108. 






































GLA UCOMA. 


297 


With the ophthalmoscope this cupping is shown by a 
sudden bending of the vessels just within the border of the 

Fig. 10S. 



Section of less advanced glaucoma cup. 

disk, where they look darker because foreshortened ; if the 
cup be deep, they may disappear beneath its edge, to reap¬ 
pear on its floor, where they have a lighter shade, Fig. 109. 



Ophthalmoscopic appearance of deep cupping of the disk in glaucoma. 

X about 15. (Altered from Liep.reich.) 

The vessels seldom all bend with equal abruptness, some 
parts of the disk being more deeply hollowed than others, 





298 


CLINICAL DIVISION. 


or some of the vessels spanning over the interval instead 
of hugging the wall of the cup. Increase of tension must 
be maintained for several months to produce cupping recog¬ 
nizable by the ophthalmoscope. When recent acute glau¬ 
coma has been cured by operation, the disk, though not 
cupped, often becomes rather hazy and very pale. Although 
usually the excavation extends from the first over the whole 
surface of the disk, it appears sometimes to begin at the 
thinnest part, the physiological pit, and spread centrifu- 
gally toward the border. A deep cup is sometimes partly 
filled up by fibrous tissue, the result of chronic inflamma¬ 
tion, and its true dimensions are not then appreciable by 
the ophthalmoscope. 

The shallowness of the anterior chamber is probably due 
to advance of the lens; it is by no means a constant symp¬ 
tom. Compression of the ciliary nerves accounts, in early 
cases, for the sluggish and usually dilated pupil, and for 
the corneal anaesthesia. In old-standing cases the iris is 
often atrophied and shrunken to a narrow rim; in uncom¬ 
plicated glaucoma iritic adhesions are never seen. The 
corneal changes depend partly on “steaminess” of the 
epithelium, partly upon haze of the corneal tissue from 
oedema (Fuchs). In recent cases, especially if acute, the 
aqueous humor and the lens appear to become somewhat 
turbid. In old cases, as already stated, the lens often be¬ 
comes slowly cataractous. There is some doubt whether 
the vitreous becomes hazy in glaucoma; it is certainly 
very seldom so when the cornea and lens are clear, and 
the point cannot be settled when these media are hazy. 
The internal pressure tends, in acute cases, to make the 
globe spherical, by reducing the curvature of the cornea 
to that of the sclerotic; it also in all cases weakens the 
accommodation, at first by pressing on the ciliary nerves, 
later by causing atrophy of the ciliary muscle ; these facts 
together explain the rapid decrease of refractive power 


GLA UCOMA. 


299 


O’. c., rapid onset or increase of presbyopia) which is some¬ 
times noticed by the patient. The choroidal circulation is 
obstructed by the increase of pressure, and in severe glau¬ 
coma, especially of old standing, the anterior ciliary veins, 
forming the episcleral plexus, Figs. 23 and 27, as well as 
the arteries, Fig. 26, become very much enlarged. 

Mechanism of Glaucoma. The increased tension is 
due to excess of fluid in the eyeball. Impeded escape is 
probably the chief cause of this excess, and recent research 


Fig. 110. 



Section through the ciliary region in a healthy human eye. Co., cornea; 
Scl., sclerotic; C. M., ciliary muscle; C.P., two ciliary processes, one larger 
than the other ; Ir., iris; L., the marginal part of the crystalline lens ; a, angle 
of anterior chamber ; d, membrane of Descemet, which ceases (as such) before 
reaching the angle, a. The dotted line shows the course probably taken by 
fluid from the anterior part of the vitreous into the posterior aqueous cham¬ 
ber, where it is augmented by aqueous humor secreted by the anterior part 
of the ciliary process, thence through the pupil (not shown) into the anterior 
aqueous chamber, to an angle, a. Suspensory ligament of lens not shown. 
X 10. 

lias proved that changes are present in nearly all glaucoma¬ 
tous eyes, which must lessen or prevent the normal out¬ 
flow. But increased secretion and internal vascular con¬ 
gestion undoubtedly play an important part in certain 
cases. Some authorities have attributed the phenomena 
of glaucoma to vasomotor changes in the size of the blood¬ 
vessels, but such hypotheses are wanting in proof. Both 














300 


CLINICAL DIVISION. 


conditions would have most effect when the sclerotic was 
most unyielding— i. e., in old age and in hypermetropic 
eyes. It is probable that there is a constant movement 
of fluid from the vitreous humor through the suspensory 
ligament of the lens, and also from the anterior part of 
the ciliary processes, into the anterior chamber, as shown 
by the dotted line in Fig. 110. The fluid escapes from the 
anterior chamber into the lymphatics and perhaps into the 

Fig. 111. 


O 



Ciliary region from a case of acute glaucoma of one month’s duration. 1 and 
2, situations of iridectomy wounds in two cases. X 10. 

Fig. 112. 



Ciliary region in chronic glaucoma of three years’ standing. X 10. 

veins of the sclerotic, through the meshes of the ligamentwn 
pectination ( Fontana’s spaces), which close the angle a ( fil¬ 
tration angle) ; and it has been proved that very little fluid 
can pass through any other part of the cornea. In glau¬ 
coma the angle a is nearly always closed, in recent cases by 
contact, in old cases by permanent cohesion, between the 
periphery of the iris and the cornea, Figs. Ill and 112. 























GLA TJCOMA. 


301 


No complete explanation of this advance of the iris has 
yet been given. Adolf Weber holds that the ciliary pro¬ 
cesses becoming swollen from various causes, push the iris 
forward, and so start the glaucomatous state. Priestley 
Smith 1 believes that the primary obstruction is at the 
narrow chink between the edge of the lens and the tips 
of the ciliary processes, “ circumlental space,” and that 
the block may depend upon one or more of three factors 
—increase in the size of the lens due to advancing years, 2 
abnormal smallness of the ciliary area, as in hypermetropia, 
and abnormal enlargement of the ciliary processes. Ob¬ 
struction of this space leads to rise of pressure in the vit¬ 
reous, followed by advance of the lens and ciliary processes 
against the base of the iris, and consequent closure of the 
angle. Brailey holds that a chronic inflammation of the 
ciliary muscle and processes, and of the iris, quickly pass¬ 
ing on to atrophic shrinking, leads to narrowing of the 
angle and initial rise of tension ; 3 in a later paper, how¬ 
ever, he agrees to some extent with the view of Weber, 
above referred to. 4 Cases of chronic glaucoma have been 
seen in which the iris was congenitally absent; in some of 
these cases the angle of the anterior chamber has been 
found blocked by the rudimentary iris. 

But there are cases which show that the matter is not 
always so simple. Stilling, of Strasburg, contended that 
the waste fluids escape by the central canal of the vitreous 
into the optic nerve, and partly also by filtration through 
the circumpapillary portion of the sclerotic, and that a 
sclerosis of these parts, by diminishing their permeability, 
leads to glaucoma; Brailey 5 states from pathological re- 

1 Priestley Smith : Transactions Ophthalmic Society, vol. vi. 1886. 

2 The increase in the size of the lens as age advances has been proved 
beyond doubt by Priestley Smith’s researches. Ibid., vol. iii. 1883. 

3 Brailey: Ophthalmic Hospital Reports, 1880, vol. x., pp. 14, 89. 93. 

4 Ibid., 1881, p. 282. 6 Ibid., pp. 86, 277, 282. 


302 


CLINICAL DIVISION. 


search that inflammation of the optic nerve is always 
present quite early in glaucoma, and that it precedes the 
increased tension; ophthalmoscopic examination in cer¬ 
tain cases lends support to this statement. 1 It may be 
added, in support of these views, that in some cases of 
glaucoma the angle of the anterior chamber remains freely 
open, and that the ophthalmoscopical appearances of glau¬ 
coma are occasionally seen without increase of T. For 
other causes, see Secondary Glaucoma, p. 308. 

An over-supply of fluid affects the tension differently in 
different cases. Congestion and ordinary inflammations 
of the retina and uveal tract do not cause glaucoma, and 
dilatation of the arteries by vasomotor paralysis is said to 
be accompanied by diminished tension. But tumors in, 
and even upon, the eye often give rise to secondary glau¬ 
coma, and probably the active congestion and transuda¬ 
tion of fluid and small cells, which occur near to a quickly 
growing tumor, are the chief factors; certainly the glau¬ 
coma stands in no constant relation either to the size or 
position of the tumor. A relation is observed in some 
cases between glaucoma and neuralgia of the fifth nerve, 
and T. is said to be lowered in paralysis of this nerve. 
Probably the pain acts by causing associated congestion, 
and thus setting up glaucoma in a predisposed eye. 

General and Diathetic Causes. In an eye predis¬ 
posed, by the changes above mentioned in the ciliary re¬ 
gion, any cause of congestion may precipitate an acute 
attack. Congestion of the eyes in connection with disturb¬ 
ances of the general circulation from heart disease, bron¬ 
chitis, or portal engorgement, or due to loss of sleep from 
gout, neuralgia, worry, etc., or caused by the over-use of 
presbyopic eyes without suitable glasses, or by a blow, or 
prolonged ophthalmoscopic examination, or exposure to 


1 Nettleship: St. Thomas’s Hospital Reports, vol. xiv. 


GLA UCOMA. 


303 


cold wind, may all bring it about. Atropine has sometimes 
caused an attack, because, by lessening the width, it in¬ 
creases the thickness of the iris, and so crowds it into the 
angle of the anterior chamber. Iridectomy on one eye 
occasionally sets up acute glaucoma in the other, probably 
by causing general excitement and disturbance, and it is 
now customary to use eserine as a preventive in the second 
eye after iridectomy in the first. Glaucoma is uncommon 
before the age of forty, and is most frequent between fifty- 
five and sixty-five ;* the rare cases seen in young adults 
and children are generally chronic and often associated 
with other changes in the eyes, particularly myopia. Acute 
cases are often dated from a period of overwork of the 
eyes, or want of sleep, as from sitting up, nursing, etc. 
Patients who have had glaucoma in one eye should be 
emphatically warned as to the danger of over-using the 
eyes, or of working without proper glasses, and against 
dietetic errors. Primary glaucoma is, according to the 
latest statistics, 2 as a whole, rather more common in women 
than men; and while the acute (congestive) forms are 
much more common in women, very chronic glaucoma are 
rather more common in men. 

Treatment. Iridectomy, or an equivalent operation, 
is, with very few exceptions, the only curative treatment. 
Eserine or pilocarpine (gr. l-ij to 5 j) used locally, how¬ 
ever, diminishes the tension in acute glaucoma, and a few 
attacks seem to have been permanently cured by it. But 
although seldom really curative, eserine is of great tempo¬ 
rary value in cases where an operation has to be deferred. 
It has little or no effect on the tension unless it cause 
marked contraction of the pupil. Eserine acts (1) by 
stretching the iris and drawing it away from the angle 

1 Statistics of 1000 cases collected by Priestley Smith, loc. cit., 1886. Gallenga 
(Turin), in 330 cases, finds the frequency greatest between sixty and seventy. 

2 Priestley Smith : loc. cit., 1886; in 1000 cases, 569 women and 431 men. 

3 Zentmayer and Posey: Archives of Ophthalmology, vol. xxiv., No. 3,1895. 


304 


CLINICAL DIVISION 


of the anterior chamber; (2) by the contraction of the 
ciliary muscle which it causes, the meshes of the tissue 
bounding this angle are more widely opened. Eserine 
causes congestion of the ciliary processes, and probably 
this explains why, if it do not soon relieve, it sometimes 
aggravates the symptoms. It is of use chiefly in recent, 
and especially in acute cases; a solution of half a grain 
or a grain of the sulphate to the ounce is to be used about 
every two hours and continued if relief be obtained. If 
in a few hours it increase the pain and do not lessen the 
T. it should be abandoned. The pain in acute cases may 
be much relieved by leeching, warmth to the eye, deriva¬ 
tive treatment, such as purgation and hot foot-baths, and 
soporifics. Cocaine is used with eserine by some surgeons, 
and seems to increase its efficacy. 

Iridectomy cures glaucoma by permanently reducing the 
tension to the normal or nearlv normal decree. It is found 

*• o 

that the best results are obtained if—(1) the path of the 
incision lie in the sclerotic from 1 to 2 mm. from the appa¬ 
rent corneal border, Fig. Ill; (2) the wound be large, allow¬ 
ing removal of about a fifth of the iris; (3) the iris be re¬ 
moved quite up to its ciliary attachment, which is best 
done by first cutting one end of the drawn-out loop of iris, 
then tearing it from its ciliary attachment along the whole 
extent of the wound, and cutting through the other end 
separately. See Operation. Puncture of the sclerotic be¬ 
hind the ciliary region has been recommended by Priestley 
Smith to relieve the tension in the vitreous chamber before 
proceeding to the iridectomy, or in cases where after iridec¬ 
tomy the tension in the vitreous chamber still remains ab- 
normally high. Evacuation of the aqueous humor by para¬ 
centesis of the anterior chamber gives only temporary relief. 

A mere wound in the sclerotic, differing but little in 
position and extent from that made for iridectomy, is suffi¬ 
cient to relieve -f- T., and to cure some cases of glaucoma 


GLA ZJCOMA. 


305 


permanently, and this operation, subconjunctival sclerotomy, 
was largely adopted by some operators a few years ago. 
Iridectomy, however, has held its ground as the more 
effectual operation. Sclerotomy is open to objection: 
(1) because the position and length of the wound are not 
perfectly under control; if too far forward and too short 
it is ineffectual, if too far back and too long there is risk 
of wounding the ciliary processes and getting hemorrhage 
into the vitreous; even shrinking of the operated eye and 
sympathetic inflammation of the other have occurred; (2) 
because the iris may prolapse into the wound and need 
removal, and the operation then becomes an iridectomy; 
(3) when the anterior chamber is very shallow, sclerotomy 
cannot be supposed to aid the exit of fluid so much as the 
removal of a piece of the iris. 

Several other operations, the principle of which is to 
make a puncture at the sclero-corneal junction, have been 
tried, but have not gained general confidence. 

Whichever operation be employed in glaucoma, the for¬ 
mation of the operation scar in the sclerotic is certainly a 
most important factor. 

Iridectomy in acute glaucoma no doubt acts at first by 
removing a portion of the iris from the blocked angle, Fig. 
99, and thus allowing the normal escape of fluid. Some 
high authorities hold, however, that its permanent effect is 
due to the formation at the seat of the wound of a layer 
of tissue more pervious to the eye-fluids than the sclerotic 
“filtration-scar an iridectomy for glaucoma which heals 
slowly is at any rate believed to be more favorable than 
one which heals immediately— i. e ., with no new tissue, and 
a slight bulging of the scar is held by some surgeons to be 
rather desirable than otherwise. That a mere sclerotomy 
may be sufficient points in the same direction. Such a 
porous scar never forms if the incision be in the cornea. 

An operation, usually iridectomy, is to be done in all 

20 


306 


CLINICAL DIVISION. 


cases of acute and subacute glaucoma, whether there be 
great pain or not, so long as some sight still remains, and 
even if all p. 1. be lost, provided that the blindness be of 
only a few days’ duration. Even if the eye be permanently 
quite blind, iridectomy or sclerotomy is sometimes prefer¬ 
able to excision of the globe for the relief of pain. 

Chronic “simple” glaucoma should, in my opinion, 
always, if possible, be operated upon early, as soon as the 
diagnosis is certain and before the field is much damaged; 
the prognosis is then fairly good. In advanced chronic 
glaucoma, when the field has become much contracted, 
visual acuteness much lowered, and the disk pale and 
considerably cupped, the rule is less clear, for it is well 
known that the effect of operation in such cases is far 
from constant. But as no other treatment is of use, and 
iridectomy is certainly often beneficial, it should usually 
be performed, especially if the disease affect both eyes. 
The patient’s prospect of life must be allowed for in 
chronic glaucoma; if he be old and feeble, life may end 
before the disease have progressed to blindness. 

There is often difficulty in deciding upon the best 
course in the so-called “premonitory” stage, which con¬ 
sists, in truth, of transient attacks of slight glaucoma. 
When it is clear that attacks of temporary mistiness and 
rainbows are glaucomatous, and that they are getting more 
frequent, iridectomy should seldom be deferred; but if the 
patient can be seen at short intervals, eserine should have 
a fair trial before operation is resorted to. It is to be re¬ 
membered that iridectomy done when sight is still good 
may, by allowing spherical aberration and causing corneal 
astigmatism, increase the defect; and this, though not of 
necessity a contraindication, must be taken into account. 

Prognosis. The prognosis after operation is, in gen¬ 
eral terms, better in proportion as the disease is acute and 
recent. If operated on within a few days of the onset of 


GLA TJCOMA. 


307 

acute symptoms, provided that fingers can still be counted 
at the time of operation, sight is often restored to the state 
in which it was at the onset— i. e., if the disease be recent 
nearly perfect sight will be restored. Even in cases com¬ 
bining the maximum of acuteness and severity, in which 
vision has for the last few days been reduced to mere p. 1., 
the operation is often successful in restoring some degree 
of useful sight. But the prognosis is not always so favor¬ 
able in acute glaucoma, especially if the patient’s health 
be much broken down ; and if there be, as is by no means 
uncommon, evidence that sight had been already damaged 
by chronic glaucoma before the acute attack set in, the 
prognosis must be guarded. In simple chronic glaucoma 
we can only hope as a rule to stop the disease where it is 
and prevent the sight from getting worse. 

The full effect of the operation is not seen for several 
weeks, though a marked immediate effect is produced in 
acute cases. In cases of long standing T. may remain 
permanently rather -j- after operation, without bad effect, 
provided it be very much less than before the operation ; 
the eye tissues can in some degree adapt themselves to in¬ 
creased pressure. 

A second iridectomy in the opposite direction, or a scle¬ 
rotomy, should be done if T., having been reduced to 
normal, or very slightly +, after the first operation, rise 
definitely, and be accompanied by a return of other symp¬ 
toms ; but several weeks should generally elapse, for slight 
waves of glaucomatous tension may occur before the eye 
has fully recovered from the first operation, and these may 
often be relieved by other means. Cases which relapse 
definitely, or which steadily get worse after the first opera¬ 
tion, are always very grave, and the second operation must 
not be confidently expected to succeed. If after iridec¬ 
tomy in acute glaucoma the symptoms are not relieved, 
even for a time, or become worse, some complication is to 


308 


CLINICAL DIVISION. 


be suspected, such as hemorrhage from the retina or cho¬ 
roid, or a tumor. See Secondary Glaucoma. 

Other Treatment. If we are obliged to delay the 
operation, the other means mentioned at p. 303 should be 
prescribed, including eserine. The diet should, as a rule, 
be liberal, unless the patient be plethoric. It is very im¬ 
portant to ensure sound sleep and mental calm. After 
the operation, until the eye has become quiet, all causes 
likely to induce congestion must be carefully avoided, such 
as use of the eyes, stooping or straining, and prolonged 
ophthalmoscopic examination. Atropine must never be 
used. We should be on the alert for the earliest symptoms 
in the second eye after operation on the first, and the use 
of eserine may be advisable as a prophylactic. 

In a few cases of very chronic or subacute character, 
with great increase of T., iridectomy seems to aggravate 
the disease, being followed not even by temporary benefit, 
but by persistence of -j- T., increased irritability, and still 
further deterioration of sight, glaucoma malignum. Per¬ 
haps the tilting forward of the lens, which sometimes fol¬ 
lows iridectomy, may account for the result. 

Glaucoma may occur independently in cataractous eyes, 
and in eyes from which the lens has been extracted, with 
or without iridectomy. 

Secondary glaucoma may be acute or chronic, according 
as it is a consequence of active disease or of sequelae. It 
may be caused by circular iritic synechia with bulging of 
the iris. Various forms of chronic irido-keratitis and irido- 
choroiditis, especially the sympathetic form, are liable to 
be accompanied by it; in the former it may be due to 
choking of the spaces of Fontana by inflammatory pro¬ 
ducts, and perhaps to excessive secretion from the ciliary 
processes; in the sympathetic disease, to total posterior 
synechia. It may follow perforation of the cornea with 
large anterior synechia. The eye often becomes temporarily 


GLA XJCOMA. 


309 


glaucomatous in the course of traumatic cataract from the 
pressure of the swollen lens on the iris and ciliary processes, 
especially in patients past middle life. In none of these 
cases is there much danger of mistaking secondary for idio¬ 
pathic glaucoma. 

But secondary glaucoma may result from various deeper 
changes. When the lens is dislocated, either behind or in 
front of the iris, it often sets up glaucoma, sometimes of a 
very severe type, apparently by pressing on the ciliary pro¬ 
cesses or iris. There is .generally the history of a blow ; and 
in posterior dislocation, even if the edge of the displaced 
lens cannot be seen, the iris is usually tremulous, and its 
surface concave or flat at one part, while bulging or promi¬ 
nent at another. If we are sure that a lens dislocated into 
the vitreous is causing the symptoms, it should be extracted 
with a scoop (see Operations); and if lying in the anterior 
chamber should also usually be removed. If the eye be¬ 
comes glaucomatous immediately after a severe blow the 
condition of the lens may not be ascertainable, and then 
an iridectomy must be done and the eye be watched; vit¬ 
reous is very likely to escape at the operation if there be 
dislocation of the lens, for the latter condition implies rup¬ 
ture of the suspensory ligament. Hemorrhage into an eye 
whose retina is detached— e. g., in high degrees of myopia, 
may give rise to acute glaucoma with severe pain. A glau¬ 
comatous attack generally occurs during the growth of an 
intraocular tumor. It is often impossible to distinguish 
such a case, in an adult, from one of idiopathic glaucoma 
of the same severity and standing; for even if the lens be 
not opaque—and it often is so—the other media will prob¬ 
ably be too hazy to allow an ophthalmoscopic examination : 
the growth itself is usually of a dark color, and both idio¬ 
pathic glaucoma and choroidal sarcoma are diseases of ad¬ 
vanced life. In almost every case, however, the glaucoma 
will be “ absolute,” and will be known to have been so for 


310 


CLINICAL DIVISION. 


weeks or months, and there will also be the negative fact 
that the fellow-eye shows no signs of glaucoma. If a glau¬ 
comatous eye, which has been absolutely blind for several 
months, remain painful and congested, and its media too 
opaque for ophthalmoscopic examination, it should be ex¬ 
cised as likely to contain a tumor. Tumors in the eyes of 
children also cause secondary glaucoma, but there is seldom 
any difficulty in making the diagnosis; the patient is far 
below the age for primary glaucoma, and the growth is 
usually conspicuous from its whitish color. Secondary 
glaucoma now and then supervenes in cases of albumin¬ 
uric retinitis, and of embolism or thrombosis of the retinal 
vessels, and in cases of retinal hemorrhage from other 
causes, hemorrhagic glaucoma. In glaucoma with hemor¬ 
rhage the diagnosis can sometimes be completed only after 
an unsuccessful operation has shown that the case is not a 
simple one. 


CHAPTER XVIII. 


TUMORS AND NEW-GROWTHS OF THE EYEBALL AND 

CONJUNCTIVA. 

A. Tumors and Growths of the Conjunctiva and 

Front of the Eyeball. 

Cauliflower warts with narrow pedicles like those on 
the glans penis, but flattened like a cock’s-comb by pres¬ 
sure, are sometimes seen on the ocular and palpebral con¬ 
junctiva. Each wart with a small portion of healthy con¬ 
junctiva around its pedicle must be snipped off, or the 
growth is likely to recur. 

Tuberculosis of the conjunctiva is found in the form of 
small gray miliary granulations in the conjunctiva of the 
upper lid ; in late stages the surface becomes ulcerated, 
ragged, and uneven, and the eyeball itself may be attacked ; 
the gland in front of the ear at the same time frequently 
becomes enlarged and suppurates. The treatment should 
be repeated free scraping with a sharp spoon, either with 
or without cauterization, to remove the tuberculous nodules 
as they appear. It is scarcely necessary to make a dis¬ 
tinction between this affection and lupus, which is of the 
same nature, but which usually attacks the conjunctiva by 
extension from the skin. 

The eyelid, especially the tarsus, is now and then the 
seat of diffused gummatous inflammation in the tertiary 
stage of syphilis. The infiltration gives rise to a hard, in¬ 
dolent swelling of the whole lid, syphilitic tarsitis. Chancres 
and tertiary syphilitic ulcers may occur on the lids. 

Papilloma of the caruncle and semilunar fold is of rare 

( 311 ) 


312 


CLINICAL DIVISION. 


occurrence, and takes the form of a pinkish cauliflower¬ 
like mass, which readily bleeds. Extirpation of the growth 
should be thorough, as it manifests a strong tendency to 
recur. Adenoma, primary sarcoma, and carcinoma of the 
caruncle also occur. 

Pinguecula, a yellowish spot, looking like adipose tissue 
in the conjunctiva, close to the inner or outer edge of the 
cornea, consists of thickened conjunctiva and subconjunc¬ 
tival tissue, and contains no fat. It is most common in old 
people and in those whose eyes are exposed to local irri¬ 
tants. Though of no consequence, advice is often asked 
about it. 

Pterygium is a triangular patch of thickened ocular con¬ 
junctiva, the apex of which encroaches upon the cornea; 


Fig. 113. 



it is almost always seated on the exposed part of the eye. 
It varies much in area, thickness, and vascularity, and 
though usually stationary may be progressive. It is to be 
distinguished from opacity of the cornea, and from the 
cicatricial band, symblepharon, which often forms between 
lid and globe after burns or wounds of the conjunctiva. 
It is rarely seen except in those who have spent some years 


TUMORS AND NEW-GROWTHS. 


313 


iii hot countries. The best treatment is, after dissecting 

7 O 

up the growth, to double it inward upon itself, drawing its 
apex into the chink between sclerotic and conjunctiva by 
means of a deep suture, which is brought out again near 
the caruncle; or to transplant the growth into a cleft in 
the conjunctiva below the cornea: excision or ligature is 
less effectual; it is important to bring the healthy conjunc¬ 
tiva over the wound by sutures after removal of the ptery¬ 
gium. Adhesion of swollen conjunctiva to a marginal 
ulcer of cornea is the starting-point of pterygium, or it 
may gradually extend from the edge of a pinguecula 
(Fuchs). 

Small thin cysts, sometimes elongated and beaded, with 
clear, watery contents, are not uncommon in the ocular 
conjunctiva near to one of the canthi. They are formed 
by distention of valved lymphatic trunks. 

Dermoid tumors (solid) of the eyeball are less frequently 
seen .than the cystic dermoids of the eyebrow. They are 
whitish, smooth, hemispherical, and firm. They gener¬ 
ally lie in the palpebral fissure, and are either wholly 
conjunctival and movable, or partly corneal and fixed. 
They are solid, and hairs may grow from their surface. 
They may be combined with other congenital anomalies 
of the eye or lids. The corneal portion of such a tumor 
cannot always be perfectly removed. 

The swelling in some cases of episcleritis , syphilitic or 
not, may be mistaken for a tumor. A few cases of inno¬ 
cent tumor on the edge of the cornea have been described 
as fibroma; it is not certain that some of these may not 
have been chronic gummata. 

Moles or patches of pigmentation of the ocular conjunc¬ 
tiva are sometimes seen; as a rule they are of no impor¬ 
tance, but in later life they sometimes become sarcomatous. 

A congenital fibro-fatty growth sometimes occurs in the 
form of a yellowish, lobulated, tongue-like protrusion be- 


314 


CLINICAL DIVISION. 


tween the lid and the globe, and usually at the outer and 
upper side of the orbit. 

Cystic tumors may be met with beneath the palpebral 
conjunctiva. The very rare form known as clacryops is a 
bluish tumor caused by occlusion and distention of a duct 
of the lachrymal gland; but other cystic conjunctival 
tumors are met with which cannot be so explained. 

Fibrous and even bony tumors are occasionally seen in 
the substance of the upper lid, perhaps starting from the 
tarsus; in one case a tooth was removed from the lower lid 
by Carver (Nagel, p. 432), and soft polypoid growths have 
been met with in the sulcus between lid and globe. 

Malignant tumors arise much less commonly on the front 
of the eye than in the choroid or retina. They may be 
either epithelial or sarcomatous. An injury is often stated 
to be the cause of the growth. 

Epithelioma may begin on the ocular conjunctiva, in 
which case it remains movable, or at the sclero-corneal 
junction, when it quickly encroaches on the cornea, infil¬ 
trates its superficial layers, and becomes fixed. It may be 
pigmented. When such a growth is not seen until late, 
it may perhaps be as large as a walnut, may cover or sur¬ 
round the cornea, and present a papillary or lobulated sur¬ 
face. The glands in front of the ear may be enlarged. 

Sarcoma in this region may or may not be pigmented. 
It generally arises at the sclero-corneal junction, and when 
small the conjunctiva is traceable over the growth. But 
in advanced cases it may be impossible from the clinical 
features to diagnose the nature of a tumor in this part. 

Movable tumors, epithelioma, not involving the cornea, 
may be cut off, but are very likely to recur; and recur¬ 
rence is still more likely in the case of growths fixed to the 
cornea or sclerotic. Removal of the eyeball at an early 
date, especially in the case of sarcomata, is the best course 
in the majority of cases. 


TUMORS AND NEW-GROIVTHS. 


315 


The lachrymal sac is occasionally the seat of new growth, 
or of tubercle which may be mistaken for chronic muco¬ 
cele. 


B. Intraocular Tumors. 

By far the most common forms are glioma of the retina 
and sarcoma of the choroid. 

Glioma of the retina is a disease of infancy or early child¬ 
hood, the patients being generally under three years old 
when first brought for treatment; it may, however, be 
present at birth, and is said occasionally to begin as late 
as the eleventh or twelfth year. Glioma is very soft, com¬ 
posed of small round cells which grow from the granule 
layers of the retina, and it either grows outward, causing 
detachment of the retina, or inward into the vitreous; 
often several more or less separate lobules are present. It 
often fills the eyeball in a few months, and then spreads 
by contact to the choroid and to the sclerotic and orbit. 
It is especially prone to travel back along the optic nerve 
to the brain; and it may cause secondary deposits in the 
brain and in the scalp, and more rarely in distant parts. 
If the eye be removed before either the optic nerve or the 
orbital tissues are infiltrated, the cure is radical; but in 
the more numerous cases, where the patient is not seen till 
what maybe called, clinically, the second stage (see below), 
a fatal return in the orbit or within the skull is the rule. 
Glioma sometimes occurs in both eyes, and in several chil¬ 
dren of the same joarents. 

The earliest symptom is a shining, whitish appearance 
deep in the eye, and the eye is soon noticed to be blind; 
as there is neither pain nor redness, advice is seldom sought 
at this stage. T. is n. or rather —. When the peculiar 
appearance has become very striking, or if the eye becomes 
painful, the child is brought to be seen. In this (the sec¬ 
ond) stage there is generally some congestion of the scleral 


316 


CLINICAL DIVISION. 


vessels, and a white, pink, or yellowish reflection from be¬ 
hind the lens (which remains clear), steaminess of the cor¬ 
nea, mydriasis, T. -j-, anterior chamber shallow and of 
uniform depth; there may be enlargement or prominence 
of the eyeball. On examination by focal light some ves¬ 
sels can generally be seen on the whitish background, and 
white specks, indicating degeneration, are sometimes 
present. 

In young children the above appearances are sometimes 
simulated by inflammatory changes in the vitreous, with 
detachment of the retina, the result of spontaneously 
arrested severe iridochoroiditis. 

Sarcoma of the choroid and ciliary body is a growth of 
late or middle life, being rarely seen below the age of thirty- 
five. The majority of these tumors are pigmented (melan¬ 
otic), some being quite black, others mottled or streaked. 
A few are free from pigment. Some are spindle-celled or 
mixed, others composed of round cells; some are truly 
alveolar, but in many specimens there is very little con¬ 
nective-tissue stroma, and no very defined arrangement of 
the cells. These tumors are moderately firm, but friable; 
some are very vascular, and hemorrhages often occur into 
them. The tumor grows from a broad base, and usually 
forms a well-defined rounded prominence, pushing the 
retina before it; blood or serous fluid is effused round its 
base, so that the retinal detachment is more extensive than 
the tumor. These tumors often grow slowly so long as 
they are wholly contained within the eye, and several 
years may elapse before the growth passes out of the eye 
and invades the orbit. Orbital infection does not usually 
occur till the globe is filled to distention by the growth ; 
but it may happen much earlier, the cells travelling out 
along the sheaths of the perforating bloodvessels and pro¬ 
ducing large extraocular growths, while the primary intra¬ 
ocular tumor is still quite small. The lymphatic glands do 


TUMORS AND NEW-G ROW TITS. 


317 


not enlarge, but there is great danger of secondary growths 
in distant parts, especially in the liver, a risk not entirely 
absent even when the eye tumor is small. Hence early re¬ 
moval of the globe is of the utmost importance, and a good, 
though not too confident, prognosis may be given when the 
optic nerve and tissues of the orbit show no signs of disease. 

Metastatic growths. In nearly every case malignant 
tumor of the choroid is primary, but it is important to 
know that growths may occur here secondary to those in 
other parts of the body; in one case, quoted by Manz, 
both eyes were affected, the original growth being cancer 
of the breast. 

Symptoms and Course. If the case be seen early, 
when defect of sight is the only symptom, the tumor can 
often be seen and recognized by its well-defined, rounded 
outline, some folds of detached retina often being visible 
near it; the pupil, cornea, and tension will probably be 
natural. When the tumor orginates in the central region 
the sight is immediately affected, and the patient seeks 
advice very early; the differential diagnosis then lies be¬ 
tween localized plastic choroiditis and tumor. In tumor 
there is often some detachment of the retina at or near the 
area of the disease, but there is no evidence of retinitis, 
and no patches of black pigment about the swelling. By 
ophthalmoscopic estimation the diseased area is found to 
be more or less raised. An inflammatory exudation of 
similar size commonly causes haze of the neighboring 
retina, and opacities in the vitreous; if of some weeks’ 
duration, part of it will usually have become absorbed, 
leaving exposed sclerotic with accumulations of pigment. 
Sooner or later the tumor in its growth sets up symptoms 
of acute or subacute glaucoma, and sometimes iritis; sub¬ 
sequently secondary cataract forms. It is in this glau¬ 
comatous (second) stage that relief is usually sought. 
Unless some part of the tumor happen to be visible out- 


318 


CLINICAL DIVISION. 


side the sclerotic, or project into the anterior chamber, a 
positive diagnosis will often now be impossible, owing to the 
opacity of the media; although by exclusion we may often 
arrive at great probability. If the eye be left alone, or 
iridectomy be performed, glaucomatous attacks and pain 
will recur, and the eye will enlarge and gradually be dis¬ 
organized by the increasing growth, which will then 
quickly fill the orbit and fungate. But sometimes a de¬ 
ceptive period of quiet follows the glaucomatous attack ; 
even decided shrinking and softening of the eye may 
occur; but the growth will sooner or later make a fresh 
start and become apparent. It is chiefly in very old 
patients that this slow course is noticed. Sarcoma is 
especially likely to form in eyes previously injured, or 
already shrunken from disease. 

Thus it is apparent that in a majority of cases of cho¬ 
roidal tumor we can only guess at the truth. We suspect 
a tumor and urge excision in the following cases : 1. When 
an eye that has been for some time failing or blind from 
deep-seated disease becomes painful, congested, and glau¬ 
comatous (there being no glaucoma of the other eye), and 
particularly if there be secondary cataract. 2. Similar 
eyes with normal or diminished tension are best excised 
as possibly containing tumor. 3. In extensive detach¬ 
ment of retina confined to one eye, without history of 
injury or evidence of myopia, the patient should be 
warned, or the eye excised, according to circumstances. 

In all cases of suspected glioma or sarcoma the eye 
should be opened at once, and if a tumor be found, the 
cut end of the optic nerve of the excised eye should be 
carefully looked at; if this be pigmented or thickened, 
another piece should be at once removed, and the orbit 
searched by the finger for evidence of growth ; the surface 
of the eye should also be carefully examined for external 
growths. When infection of the nerve or orbit is sus- 


TUMORS AND NEW-GROWTHS. 


319 


pec ted, the orbit should be cleared out and chloride of 
zinc paste applied. 

Tumors of the iris are rare. Melanotic as well as unpig- 
mented sarcomata are occasionally met with. 1 The definite 
development of melano-sarcoma of the iris has been known 
to be preceded for many years by an apparently innocent 
pigmented spot on the iris. In eyes blind and degenerated 
after iridocyclitis, the uveal pigment may increase in 
amount, and creep round the pupillary border to the 
anterior surface of the iris; these areas of new pigment 
might be mistaken for melanotic growths. Sebaceous or 
epithelial tumors are also seen; they are nearly always 
the result of transplantation of epithelium, or of a hair, 
into the iris through a perforating wound of the cornea; 
they are frequently cystic, implantation cysts. In rare 
cases cystic tumors with thin walls are formed between 
the layers, or connected with the posterior surface of the 
iris, particularly in eyes which have been operated on or 
otherwise injured. 

Diffuse sarcoma of iris. Sarcoma of the iris may be 
white or pigmented: it usually takes the form of a single 
large prominent growth. I have twice seen a sarcoma 
of the iris take the form of a diffused thickening, with a 
mottled or tortoise-shell aspect; such a diffuse form is more 
difficult to diagnose, and probably more dangerous, if left 
alone, than a definite tumor. 

Cases of disease of the iris are seen from time to time, 
the special feature of which is the presence of one or more 
nodular growths, usually of small size; iritis is generally 
present. It is often impossible to determine the nature of 
the growth until the case has been watched, or microscop¬ 
ical examination or inoculation experiments have been 

1 A well-reported case, with numerous references, is given by Little, in 
Trans. Ophth. Soc., vol. iii. 1883. 


320 


CLINICAL DIVISION. 


made. These cases, which have often been described as 
granuloma of the iris, are certainly sometimes tubercle, 
sometimes chronic gummata, sometimes part of a severe so- 
called serous iritis, and sometimes the nature of the growth 
is doubtful. Inoculation of tuberculous material into the 
anterior chamber of rabbits has repeatedly been followed 
by the formation of multiple nodules, similar in appear¬ 
ance to those in some of these cases, and some of the 
growths in human cases have given the microscopical 
reactions of true tubercle. The disease is probably tuber¬ 
cular when the growths are multiple, non-vascular, and 
gray, especially when accompanied by enlarged glands in 
the patient, or a family history of tubercle. 

Large masses of confluent tubercle occasionally form in 
the choroid or other parts of the uveal tract, leading to 
disorganization of the eye, with mixed symptoms of intra¬ 
ocular growth and inflammation. As it is probable that 
this ocular tubercle may be a source of general tubercu¬ 
losis, excision of the eye is the best course in any doubtful 
case where it is clear that the eye is lost. 

The cornea is much less liable to tubercular infiltration 
than the iris, but small growths have been observed in it, 
both as the result of inoculation and in the course of spon¬ 
taneous tubercle of the iris. 

C. Tumors of the Orbit. See Chapter XIX. 


CHAPTER XIX. 


INJURIES, DISEASES, AND TUMORS OF THE ORBIT. 

1. Contusion and concussion injuries. Bruising of the 
eyelids from direct blows—“ black eye ”—may usually 
with care be distinguished from the deeper extravasation 
following fracture of the walls of the orbit. In ordinary 
“ black eye” the ecchymosis comes very quickly and re¬ 
mains superficial, and, if it affect either the palpebral or 
ocular conjunctiva, does not pass far back. The ecchy¬ 
mosis following fracture of the orbital plate of the frontal 
bone comes more gradually, is deep-seated, often entirely 
beneath, rather than in, the skin and conjunctiva, dimin¬ 
ishes in density toward the front and borders of the lids, 
and, when considerable, causes proptosis. But if a frac¬ 
ture involve the rim of the orbit, the above characters are 
likely to be mixed, and therefore misleading. Wasting 
of the adipose tissue of the orbit, and consequent sinking 
back of the eye, sometimes follow severe blows, with much 
extravasation of blood (enophthalmos). 

Fracture of the inner wall of the orbit into the nose, the 
sinuses opening into it, or the nasal duct, is often followed 
by emphysema of the orbital cellular tissue. This can occur 
only when the mucous membrane is torn. The emphysema 
comes on quickly from “ blowing the nose,” and is shown 
by a soft, whitish, doughy swelling of the lids, which crepi¬ 
tates finely under the finger; the globe is more or less 
protruded and its movements limited. The emphysema 
disappears in a few days if the lids be kept bandaged. 
These fractures are usually caused by blows over the inner 

21 ( 321 ) 


322 


CLINICAL DIVISION. 


angle of the orbit, but occasionally by blows on the malar 
region. 

Partial ptosis is an occasional result of blows upon the 
upper lid. It is generally accompanied by paralysis of 
accommodation and dilatation of the pupil, and it seldom 
lasts more than a few weeks. Ocular paralysis following 
injury to head. See Chapter XXI. 

2. Orbital abscess and orbital cellulitis may follow in¬ 
juries, but their origin is often obscure. Cellulitis may 
spread to the orbit from the face in erysipelas, from the 
throat in severe tonsillitis, or from the socket of an in¬ 
flamed tooth. Diffused acute inflammation of the cellular 
tissue is difficult to distinguish from acute orbital abscess, 
since in both there are the signs of deep inflammation, 
with displacement of the eye and limitation of its move¬ 
ments, chemosis of the conjunctiva, and brawny swelling 
and redness of the lids. An acute abscess soon points be¬ 
tween the globe and some part of the rim of the orbit, but 
even in cellulitis the swelling may be greater at some one 
part, and give rise to a feeling deceptively like fluctuation. 

Orbital abscess may be so chronic as to simulate a solid 
tumor until the pus nears the surface; even then an ex¬ 
ploratory incision may be needed to set the question at 
rest. Abscess of the orbit, whether acute or chronic, is 
very often the result of periostitis, and a large surface of 
bare bone is often found with the probe. 

In acute cases, as soon as fluctuation is certain, an in¬ 
cision is to be made with a narrow, straight knife, gener¬ 
ally through the skin, or, if practicable, through the 
conjunctiva. Chronic cases of doubtful nature may be 
watched for a time. It may be necessary to go deeply 
into the orbit, either with the knife, probe, or dressing 
forceps, before matter is reached. A drainage-tube should 
be inserted if the abscess be deep. The proptosis does not 
always disappear when the abscess is opened; it may in- 


INJURIES, DISEASES, AND TUMORS OF ORBIT. 323 


crease owing to hemorrhage, and there may be much 
thickening of the tissues. Sight may be injured or lost 
by stretching of, or pressure on, the optic nerve, and the 
cornea may lose sensation, and ulcerate from damage to 
the ciliary nerves behind the globe. 

Thrombosis of the cavernous sinus, which may result 
from several causes, produces local symptoms which it is 
difficult, often impossible, to distinguish from those of cellu¬ 
litis beginning in or limited to the orbit. The thrombosis, 
however, often spreads to the other cavernous sinus and 
the other orbit; and in any case it produces the gravest 
head symptoms, which, as a rule, end fatally in a short 
time. 1 

3. Wounds. Wounds of the eyelids need no special 
treatment beyond very careful apposition by sutures, 
sometimes with a small harelip pin, so as to secure 
primary and accurate union. Lacerated wounds of the 
ocular conjunctiva, if extensive, need a few fine sutures, 
and they seldom lead to any deformity. When a rectus 
tendon has been torn through I have never succeeded in 
getting the ends to unite. 

Penetrating wounds through the lids or conjunctiva, 

which pass deeply into the orbit, may be much more 
serious than they appear at first sight, since the wounding 
body may have caused fracture of the orbit and damage 
to the brain membranes, or a piece of the wounding in¬ 
strument may have been broken off and lie embedded in 
the roomy cavity of the orbit, without at first exciting 
disturbance or causing displacement of the eye. Some 
extraordinary cases are on record 2 in which very large 
foreign bodies have lain in the orbit for a long time unde¬ 
tected. The optic nerve is occasionally torn across with- 

1 An able paper on this little-known subject has been communicated to the 
Ophthalmological Society by Dr. Sidney Coupland, October, 1886. 

2 In Mr. Lawson’s well-known treatise and elsewhere. 


324 


CLINICAL 1)1 VISION. 


out damage to the globe. Every wound of the eyelids or 
conjunctiva should, therefore, be carefully explored with 
the probe, and, whenever possible, the instrument which 
caused the wound should be examined. 

When a foreign body is suspected or known to be firmly 
embedded, and is not removable through the original 
wound, it is generally best to divide the outer canthus, 
and prolong the incision into the conjunctiva; in some 
cases an incision through the skin over the margin of the 
orbit, at the situation of the foreign body, will be prefer¬ 
able. Single shot, embedded and causing no symptoms, 
should not be interferred with unless they can be easily 
reached. 

Wounds of the orbit, by gunshot or other explosives, 
when extensive and caused by numerous shots or frag¬ 
ments of sand, gravel, etc., driven into the tissues, are of 
course serious, particularly if the eyeball itself be injured. 
Such injuries may cause tetanus. 

Tumors of the Orbit. 

A tumor of any notable size in the orbit always causes 
protrusion of the eye (proptosis), with or without lateral 
displacement and limitation of its movement. As a rule, 
there are no inflammatory symptoms. An exact diagnosis 
of the seat, attachments, and nature of an orbital tumor 
is, of course, often impossible before operating ; and it may 
be further observed that there has occasionally been great 
difficulty in deciding whether the symptoms pointed to a 
tumor, or to some form of chronic hypertrophy of cellular 
tissue or quiet gummatous inflammation. 

A tumor in the orbit may originate in some of the loose 
orbital tissues, in the lachrymal gland, in the periosteum, 
upon or within the eyeball, or from the optic nerve; or it 
may have encroached upon the orbit from one of the neigh- 


INJURIES, DISEASES, AND TUMORS OF ORBIT. 325 


boring cavities. Fluctuating tumors in the orbit may be 
cystic or ill-defined, and may or may not pulsate. Solid 
tumors in the orbit may be movable, or be fixed by broad 
attachments to the wall of the cavity. Sight is often dam¬ 
aged or destroyed in the corresponding eye by compression 
or infiltration of the optic nerve. 

1. Distention of the frontal sinus by retained mucus 
causes a well-marked, fixed, usually very chronic swelling, 
not adherent to the skin, at the upper inner angle of the 
orbit above the tendo oculi. Hard at first, it fluctuates 
when the bony wall has been absorbed. Its course is usu¬ 
ally slow, but acute suppuration may supervene, and the 
swelling be mistaken for a lachrymal abscess (p. 97). 
There is generally a remote history of injury. The aim 
of treatment is to re-establish the opening, closed probably 
as the result of fracture, between the floor of the sinus and 
the nose. The most prominent part of the swelling is freely 
opened ; a curved probe is then passed, if possible, from the 
sinus through the infundibulum into the nose; if the open¬ 
ing has been completely closed, it is sometimes necessary 
to perforate the base of the sinus by a trocar. A seton or 
drainage-tube is then passed through the hole, brought 
out at the nostril, and must be worn for several weeks or 
months. Cases of the same nature are sometimes seen in 
which the swelling is at a lower level and further back in 
the orbit; they are not connected with the frontal sinus, 
but are probably due to distention of some of the cavities 
of the ethmoid. 

2. Pedunculated ivory exostoses sometimes grow from the 
walls of the same sinus or its neighborhood; beginning 
early in life, they increase very slowly, cause absorption 
of their containing walls, and often in the end undergo 
spontaneous necrosis and fall out. Their removal while 
still fixed is very difficult and dangerous, owing to the 
proximity of the dura mater. 


326 


CLINICAL DIVISION 


3. Tumors encroaching on one or both orbits from the 
base of the skull, the antrum, the nasal cavity, or the 
temporal fossa, generally admit of correct diagnosis. 

The suspicion of tumor on the inner or lower wall of 
the orbit should always lead to an examination of the 
palate, pharynx, and teeth, of the permeability of each 
nostril, of the functions of the cranial nerves, of the state 
of the glands behind the jaw on both sides, and to an 
inquiry as to epistaxis or discharge from the nose. 

4. Pulsating tumors of the orbit and cases of proptosis 
with pulsation are in most cases due to arterio-venous in¬ 
tercommunication in the cavernous sinus, in consequence 
of which the ophthalmic vein and its branches become 
greatly distended with partially arterialized blood. In 
a large proportion the symptoms follow rather gradually 
after a severe injury to the head. In others they come on 
suddenly with pain and noises in the head, without appa¬ 
rent cause, and these idiopathic cases are usually in senile 
persons. In several examples of both forms a communi¬ 
cation has been found, post mortem, between the internal 

' carotid artery and the cavernous sinus, the result of wound 
from fracture of the base of the skull in the traumatic cases, 
and of rupture of an aneurism in the idiopathic ones. The 
typical symptoms are proptosis, with chemosis, pulsation of 
the eyeball, paralysis of orbital nerves, a soft, pulsating 
tumor under the inner part of the orbital arch, and a 
bruit. A bruit with proptosis and conjunctival swelling 
may be present without demonstrable tumor or pulsation. 
Ligature of the common carotid has been practised with 
good results in a large number of cases; subsequent ex¬ 
cision of the eye and evisceration of the orbit for a dan¬ 
gerous return of symptoms in one or two. An unruptured 
aneurism of the internal carotid does not cause the symp¬ 
toms just described. Aneurism of the intra-orbital arteries 
and arterio-venous communications in the orbit, if they 


INJURIES ; DISEASES, AND TUMORS OF ORBIT. 327 


occur, are excessively rare. Erectile tumors, well defined 
aud separable, but not causing decided pulsation, are some¬ 
times met with in the orbit, and can be dissected out. 

5. A fluctuating tumor which does not pulsate, is not 
inflamed, and not connected with the frontal sinus or 
lachrymal gland, may be a chronic orbital abscess (p. 
322), a hydatid, or a cyst containing bloody or other 
fluid, and of uncertain origin. An exploratory puncture 
should be made after sufficiently watching the case, and 
the further treatment must be conditional. Perfectly 
clear, thin fluid probably indicates a hydatid, and in this 
case the swelling is likely to return after a puncture, and 
the cyst will need removal through a free opening. The 
echinococcus hydatid often contains daughter-cysts, some 
of which escape puncture. Suppuration may take place 
around any species of hydatid. 

6. Examination leads to the diagnosis of a solid tumor 
limited to the orbit. We must try to determine whether 
the growth began in the eyeball or optic nerve, or in some 
of the surrounding tissues. We therefore examine the 
globe for symptoms of intraocular tumor (p. 315). 

Solid growths independent of the eyeball may arise as 
follows : (a) From th e periosteum; these are firmly attached 
by a broad base, are generally malignant, and seldom admit 
of successful removal. (5) The lachrymal gland may be the 
seat of various morbid growths, including carcinoma; a 
great part of the growth is in the position of the gland, and 
can be explored by the finger. Although such a growth is 
often attached firmly to the orbital wall, its position, lobu- 
lated outline, and well-defined boundary will often lead 
to a correct diagnosis. Tumors of the lachrymal gland 
should always be removed if they are increasing, for 
we can never feel sure that they are innocent, (c) Solid 
tumors originating in some of the softer orbital tissues, 
especially the form known as cylindroma, or plexiform sar- 


328 


CLINICAL DIVISION. 


coma, occur more rarely. ( d ) Tumors of the optic nerve, 
usually myxomatous, occur, though rarely j 1 they gener¬ 
ally cause neuro-retinitis and blindness, but no absolutely 
pathognomonic symptoms; they may sometimes be extir¬ 
pated without removing the globe. 

When an orbital tumor is found during operation to be 
adherent to bone or to infiltrate soft parts which cannot be 
removed, chloride of zinc paste (F. 14) should be applied 
on strips of lint, either at once or the next day when 
oozing has ceased. If the periosteum be affected, it is to 
be stripped off, and the paste applied to the bare bone. 
Hemorrhage from the depth of the orbit can always be 
controlled by a firm, graduated compress. 

In every case of suspected primary orbital tumor the 
question of syphilis must be carefully gone into; although 
neither periosteal nor cellular nodes are common in the 
orbit, both are known to occur and to disappear under 
proper treatment. 

Nsevus may occur on the eyelids and in the orbit, and 
implicate the conjunctiva, both of the lids and eyeball. 
Deep noevi may degenerate and become partly cystic. 
Some cases of nsevus of the face are associated with 
nsevus of the choroid; in such the eyes are generally 
very defective. 

Dermoid tumors ( cystic ) are not uncommon at the outer 
end of the eyebrow; more rarely they occur near the inner 
canthus. Lying deeply beneath the orbicularis, they are 
not adherent to the skin like sebaceous cysts; the sub¬ 
jacent bone is sometimes hollowed out. They often grow 
faster than the surrounding parts, and should then be ex¬ 
tirpated, the thin cyst-wall being carefully and completely 
removed through an incision parallel with, and situated 
in, the eyebrow. They usually contain sebaceous matter 
and short hairs; occasionally, clear oil. 

1 For references see Knapp’s Archives of Ophthalmology, xii. 292. 


CHAPTER XX. 


ERRORS OF REFRACTION AND ACCOMMODATION. 

As stated at p. 29, § 19, when the length of the eye is 
normal, and the accommodation relaxed, only parallel rays 
are focussed on the retina, and, conversely, pencils of rays 


Fig. 114. 



Pencils of parallel rays entering or emerging from an emmetropic eye. 


emerging from the retina are parallel on leaving the eye, 
Fig. 114, and this, the condition of the normal eye in 
distant vision is called emmetropia (E.). All permanent 


Fig. 115. 



Emmetropia. Distant objects (parallel rays) focussed on retina ; near objects 
(divergent rays) focussed behind retina. 


departures from the condition in which, with relaxed 
accommodation, the retina lies at the principal focus, are 
known collectively as ametropia. 


( 329 ) 





330 


CLINICAL DIVISION. 


In E. rays from any near object, e. g ., divergent rays 
from Ob, Fig. 116, are focussed behind the retina at cf, 
every conjugate focus being beyond the principal focus 
(p. 22, § 13). Reaching the retina before coming to a 
focus, such rays will form a blurred image, and the object 
Ob will therefore be seen dimly. But by using accom¬ 
modation the convexity of the crystalline lens can be 
increased and its focal length shortened, so as to make 
the conjugate focus of Ob coincide exactly with the retina 
(cf, Fig. 116). Under this condition the object Ob will 


Fig. 116. 



Eye during accommodation. Near objects (divergent rays) focussed on 
retina ; distant objects (parallel rays) focussed in front of retina. The dotted 
line in front of the lens shows its increase of convexity. 

be clearly seen, while the focus of a distant object, which 
in Fig. 115 was formed on the retina, will now lie in front 
of it (f, Fig. 116), and the distant object will appear in¬ 
distinct. The nearest point of distinct vision (p) and the 
farthest (r) have been defined at p. 50. 

Myopia (M.). 

In Fig. 115, if the retina were at cf instead of at f, a 
clear image would be formed of an object at Ob, without 
. any effort of accommodation, while objects farther off 
would be focussed in front of the retina. This state, in 
which the posterior part of the eyeball is too long, so that, 
with the accommodation at rest, the retina lies at the con¬ 
jugate focus of an object at a comparatively small distance, 
is called short-sight or myopia (M.), axial myopia. 




REFRACTION AND ACCOMMODATION. 331 


In Fig. 117 the inner line at r is the retina, and f the 
principal focus of the lens-system— i. e., the position of the 
retina in the normal eye. Rays emerging from r will, on 
leaving the eye, be convergent, and, meeting at the con¬ 
jugate focus r', will form a clear image in the air. Con¬ 
versely, an object at r' will form a clear image on the 
retina (r), compare Figs. 10 and 12. The image of every 
object at a greater distance than r' will be formed more 
or less in front of r, and every such object must, therefore, 
be seen indistinctly. But objects nearer than r' will be 
seen clearly by exerting accommodation, just as in the 
normal eye, Figs. 115 and 116. 


Fig. 117. 



Myopia. Retina beyond principal focus, hence only near objects (divergent 

rays) focussed on retina. 

In M. the indistinctness of objects beyond the far point 
(r) is lessened by partially closing the eyelids. This habit 
is often noticed in short-sighted people who do not wear 
glasses, and from it the word myopia is derived. 

The distance of r (r', Fig. 117) from the eye will depend 
on the distance of its conjugate focus r — i. e., upon the 
amount of elongation of the eye. The greater the distance 
of r beyond f, the less will be the distance of its conjugate 
focus r' (=r); in other words, the higher will be the M., 
and the more indistinct will distant objects be. If the 
elongation of the eye be very slight, r nearly coinciding 
with f, r' (= r) will be at a much greater distance (com¬ 
pare p. 23, § 16), and distant objects will be less indistinct. 
As the retinal images formed in a myopic eye are larger 




332 


CLINICAL DIVISION. 


than normal (p. 23), myopic persons can distinguish smaller 
objects at the same distance than those with normal eyes. 

Symptoms of M. In low degrees the patient’s com¬ 
plaint is that he cannot see distant objects clearly; in 
moderate and high degrees it is rather that he can see 
distinctly only when things are held very close, for objects 
a few feet off are so indistinct that many such persons 
neglect them. Adults often tell us that their distant sight 
was good till about eight or ten years of age, that it then 
began to shorten, and that the defect after increasing for 
several years at length became stationary. 

In high degrees of M. the patient is apt to complain 
of special difficulty in seeing at night, probably because, 
(1) the mobility of the eye being below normal, the field 
of fixation (p. 55) is diminished, and (2) the elongation of 
the eye by altering the position of the retina leads to some 
narrowing of the field of indirect vision (p. 54). 1 

In many cases no other complaint is made, but in a cer¬ 
tain number complications are present. There is often in¬ 
tolerance of light, an additional cause for the half-closed 
lids and frowning expression so often noticed. Aching of 
the eyes is a very common and troublesome symptom, and 
is especially frequent if the M. is increasing; it is often 
brought on, and always made worse, by over-use of the 
eyes, but sometimes it is very troublesome when quite at 
rest, and even in bed at night. One or both internal recti 
often act defectively, so that convergence of the optic axes 
for near vision becomes difficult, painful, or impossible, and 
various degrees of divergent strabismus result; this occurs 
oftenest, but by no means only, in the higher degree of M. 
where r is so near that binocular vision involves a strong 
effort of convergence. When this “ muscular asthenopia,” 
or “insufficiency of convergence,” is slight or intermittent 

1 Wecker and Landolt: Traite, t. i. p. 595. Landolt: Refraction and Ac¬ 
commodation of the Eye, p. 425. 


REFRACTION AND ACCOMMODATION. 


333 


it causes indistinctness or “ dancing ” of the print, and 
sometimes actual diplopia, besides the other discomforts 
above mentioned; but diplopia is seldom present when a 
constant divergent squint has been established. 

This tendency to divergence in M. is also partly due to the 
natural association between relaxation of the ciliary muscles 
and of the internal recti—the converse of convergent squint 
in H. 

The lower degrees of M. are sometimes accompanied by 
involuntary contraction of the ciliary muscle (“ spasm of 
accommodation ”) by which M. is temporarily increased; 
and the habitual approximation of objects, which thus 
becomes necessary, is one cause of still further elougatiou 
of the eye and increase of the structural M. Floating 
specks, muscce volitantes, are especially common and trouble¬ 
some in myopia. 

Objective Signs and Complications. In high de¬ 
grees of M. the sclerotic is enlarged in all directions, Fig. 
120; the eye being too large, often looks too prominent, 


Fif. 118 . 



Section of a highly myopic eyeball. The retina has been removed. 

and its movements are somewhat impeded. But apparent 
prominence of the eye may depend on many other causes. 

The existence of M. is made certain by the ophthalmo¬ 
scope in four different ways: 

1. By direct examination, the image of the fundus formed 
in the air, Fig. 117, is clearly visible to the observer if he 





334 


CLINICAL DIVISION. 


be not nearer to it than his own near point. The image 
is inverted and magnified, the enlargement being greater 
the further it is formed from the patient’s eye— i. e., the 
lower the M. For very low degrees this test is not easy 
to use, because of the great distance (3' or 4' e. g .) that must 
intervene between observer and patient; but it is easily 
applied if the image be not more than 2' in front of the 
patient. 

2. By indirect examination the disk in M. appears smaller 
than usual. If now the object lens be gradually withdrawn 
from the patient’s eye, the disk will seem to grow larger. 
This appearance, which depends on a real increase in size 
of the aerial image, is less evident the lower the M., Fig. 

119, C. 

3. By direct examination no clear view of the fundus is 
obtained if the distance between patient and observer be 
less than that between patient and inverted aerial image, 
Fig. 104, r' ; and as r' is in front of the myopic eye, the 
image will always be invisible if the observer go close to 
the patient. Hence, if on going close to the patient the 
observer cannot, either by relaxing or using his accommo¬ 
dation, see any details of the fundus clearly, the patient is 
myopic, opacities of the media being of course excluded. 
This test is applicable to all degrees of M., accommoda¬ 
tion being completely relaxed. 

4. By retinoscopy with a plane mirror the shadow ob¬ 
tained on rotating the mirror moves against the direction 
of rotation. The tests 1, 2, and 4 are, on the whole, most 
generally useful for beginners. 

In a large proportion of cases the elongation of the eye 
causes atrophy of the choroid on the side of the optic disk 
next to the y. s., the apparent inner side in direct exami¬ 
nation. This atrophy gives rise to a crescentic patch, Fig. 

120, of yellowish-white or grayish color, whose concavity is 
formed by the border of the disk, while its convex side 


REFRACTION AND ACCOMMODATION. 



336 


CLINICAL DIVISION. 


curves toward the y. s. ; it is known as a “ myopic 
crescent,” also as a “ posterior staphyloma,” because it 
indicates a localized bulging of the sclerotic, Fig. 118. 

Fig. 120. 



Myopic crescent or small posterior staphyloma. (Wecker and Jaeger.) 

It varies in size from the narrowest rim to an area several 
times that of the disk, and may form a zone entirely sur¬ 
rounding the disk, Fig. 121, instead of a crescent; there 

Description of Fig. 119. The figure shows the effect on the size of the in¬ 
verted image caused by withdrawing the objective lens from the eye, in the 
indirect ophthalmoscopic examination. 

A shows that in emmetropia the image remains of the same size on with¬ 
drawal of the lens. Ob is the retina lying at the principal focus of the diop¬ 
tric media of the eye, represented by L; l and l' show the objective lens at 
different distances from the eye; Ini and Ini' the ophthalmoscopic images 
formed in each case. Rays from any point on Ob emerge from L parallel, 
and are united by l at the point lm (the principal focus of l for the rays indi¬ 
cated) on the secondary axis 1, -which forms with the principal axis the angle 
a. If l be removed to l ', it will still intercept some of the same bundle of paral¬ 
lel rays, and these will be united in lm' at the same distance as before, on the 
secondary axis 2, which forms with the principal axis the angle 6 = the angle 
a. The relative sizes of lm and lm' depend on (1) their respective distances 
d and d' from the lens, and (2) on the size of the angles a and b. As in the 
present case d = d and a = b, lm must = lm'. 

B shows the diminution of the image in hypermetropia. The lettering is 
as before, but f is the principal focus of l, and v. f. the virtual focus of the 
retina Ob. The letters d and d' are omitted, but can easily be supplied. The 
angle b is now smaller than a, because the rays emerge from l divergent (as 
if from v. f.), and hence (d and d' being nearly equal) lm' must be smaller 
than lm. 

C shows the increase of the image in myopia ; the retina Ob is now beyond 
f ; c. F. is the “ far point ” of the eye, conjugate to Ob. The angle b is now 
larger than a because the rays emerge from l convergent (toward c. F.), and 
hence (d and d' still being nearly equal) lm' must be larger than lm. 










































REFRACTION AND ACCOMMODATION. 337 


may also be several spots of atrophied or thinned choroid, 
beyond the bounds of the crescent, and these also occur in 
horizontal lines near the y. s. Extensive choroidal changes 
are generally assumed to be the result of choroiditis, “my¬ 
opic choroiditis ” (p. 223). As a rule, the higher the M. 
the more extensive are the choroidal changes, but the rela¬ 
tion is by no means constant, and occasionally even in 
high degrees we find no crescent. Hemorrhages may 
occur from the choroid in the same region, and leave 
some residual pigment. Owing to the steepness of the 


Fro. 121. 



Large annular posterior staphyloma. (Liebreich.) 

bulging the disk is often tilted and appears oval because 
seen at “ three-quarter face” instead of “ full face,” Fig. 
121. It is sometimes very pale on the side next the y. s. 
when the staphyloma is large. 

There is in M. a great liability to liquefaction of, and 
the formation of opacities in, the vitreous, and, still worse, 
to detachment of the retina. A large proportion of all 
retinal detachments occur in myopic eyes. A blow on the 
eye sometimes appears to have caused the detachment, 
though often not until after a considerable interval. In 
high degrees of M. the lens frequently becomes cataractous, 

22 




































338 


CLINICAL DIVISION. 


the cataract generally being cortical and complicated with 
disease of the vitreous. 

Thus we arrive at a sum total of serious difficulties and 
risks to which myopic persons are subject, especially when 
the myopia is of high degree. It is only when the degree 
is low (2 D. or less), and the condition stationary, that the 
popular idea of “ short sight ” being “ strong sight ” is at 
all borne out, or that the later onset of presbyopia (p. 362) 
counterbalances the disadvantages of bad distant vision. 

Causes. M. is very rarely present at birth ; the elonga¬ 
tion of the globe which constitutes M. comes on gradually 
during the growing period of life, and especially between 
the ages of ten and twenty ; l the eye begins to elongate 
during childhood. Though M. is strongly hereditary, it 
may also begin independently, especially from the pro¬ 
longed use of the eyes for near work. The strain on the 
internal recti, counterbalanced, it may be, by a corre¬ 
sponding tension on the external recti, is believed to act 
by compressing the eyeball, and thus causing the unpro¬ 
tected posterior pole of the sclerotic to bulge. The con¬ 
comitant tension of the ciliary muscle probably aids by 
bringing on congestion of the uveal tract, as it certainly 
appears to do of the disk, and thus predisposes to soften¬ 
ing and yielding of the tunics; to this congestion the 
habit of stooping over the book or work contributes by 
retarding the return of blood. It is evident that if such 
causes are able to start the disease they must constantly 
tend to increase it. M. seldom increases after the age of 
twenty-five, unless under special circumstances; but gene¬ 
ral enfeeblement of health, as after severe illness or pro¬ 
longed suckling, seriously increases the risk of its progress, 
even after middle life. Any condition in which during 
childhood better vision is gained by holding objects very 

1 Recent examinations by Schleich and Germann upon several hundred 
infants show that the human eye is almost invariably hypermetropic at birth. 


REFRACTION AND ACCOMMODATION. 339 


close is likely to bring on M.; and so we find it dispropor* 
tionately common among those who from childhood have 
suffered from corneal nebulte, partial (especially lamellar) 
cataract, severe choroiditis, or a high degree of astigma¬ 
tism. A bad supply, or bad arrangement, of light, bad 
print, and seats or desks so proportioned as to encourage 
children to stoop over their lessons, are now generally 
believed to be largely answerable for the production of 
myopia. It is, however, to be noted that some of the very 
worst cases occur in persons who have never used their 
eyes for close observation of any kind. 

Treatment. The treatment is divisible into (1) pro¬ 
phylactic and (2) remedial. 1. Much may be done to pre¬ 
vent M., or to check its increase when it has began, by 
regulating the light, books, and desks used by children, so 
as to remove the temptations to stooping. Children should 
not be allowed to read or work by flickering or dull light; 
and as we write and read from L. to R., it is best, when¬ 
ever possible, to admit the light from the left, so that the 
shadow of the pen is thrown toward the right, away from 
the object looked at. A myopic child should not be allowed 
to fully indulge his bent, which is generally strong, for 
excessive reading. 2. By means of suitable glasses (a) dis¬ 
tant objects may be seen clearly— i. e., the eye be rendered 
emmetropic, (6) reading and working become possible at a 
greater distance. The strain on the internal recti usually 
ceases when the gaze is directed into the distance, whether 
vision be distinct or not; glasses for distant vision have, 
therefore, no effect on the progress of the myopia, and are 
of value only for educational purposes, that the patient 
may see what is about him as clearly as other people; 
their use is, therefore, to a great extent optional. But if 
we can increase the distance of the natural far point (r) 
from the eyes, we lessen the tension on the internal recti 
in near vision, diminish the temptations to stooping and 


340 


CLINICAL DIVISION. 


to reading by bad light, and so help to check the progress 
of the disease; hence glasses for near work are very impor¬ 
tant in the higher degrees of M. (3 D. and more) in early 
life. When M. has been stationary for years, however, the 
decision even on this point may be left to the patient. 

Before ordering glasses for either purpose we must 
measure accurately the degree of M. In Fig. 122, let r 
be the far point, and let it be 25 cm. in front of the 
patient’s eye, so that he can see nothing clearly at a 
greater distance than 25 cm. 

(a) He is required to see distant objects (objects seen 
under parallel rays) clearly. A concave lens is interposed 
of strength sufficient to give to jmrallel rays a degree of 
divergence, as if they came from r, Fig. 122. The focal 


Fig. 122. 



Myopia corrected by concave lens. 


length of this lens will be the same as its distance from r; 
and, as it is placed close to the eye, its focal length will be 
very nearly the same as (a little shorter than) the patient’s 
far point. Therefore, if we measure the distance of r from 
the patient’s eye, a lens of nearly the same focal length will 
neutralize his M. He will choose a lens rather higher 
than this test would lead us to expect if the M. be uncom¬ 
plicated ; l while if, owing to complications, there be con- 

1 It is sometimes stated that the glass chosen for distance is rather weaker 
than is indicated by the distance of r from the crystalline lens, the associated 
accommodation having caused an apparent increase of M. This is true only 
in low degrees of M., and not always in them ; most patients choose a rather 
stronger lens than is indicated by r— i. e., a lens whose focus is shorter by the 
distance between its own central point and the cornea. 




REFRACTION AND ACCOMMODATION. 341 


siderable defect of vision, he will often choose a somewhat 
lower glass. Hence, it is a good rule to begin the trial with 
a lens weaker than the one which, judging by the above 
test, we expect the patient to choose, and to try succes¬ 
sively stronger ones till the best result is reached. The 
weakest concave glass which gives the best attainable sight 
for the distant test types (p. 48) is the measure of the M., 
and this glass, but not a stronger one , may be safely worn 
for distant vision. Beginners often test M. patients with 
concave glasses for near types; neither + nor — glasses 
give any information about the refraction when used for 
near objects, since they merely either substitute or call 
into use the accommodation. 

(6) A glass is needed with which the patient will be able 
to read or sew at a distance greater than his natural far 
point. Theoretically the fully correcting glass (a) would 
suit, since it gives to all the rays a course which, in relation 
to the myopic eye, is the same as that of the rays entering 
a normal eye. But this glass can seldom safely be allowed 
in the higher degree of M. The lens which fully corrects 
the myopia diminishes the size of the retinal images so 
much (p. 30) that the patient is tempted to enlarge them 
again by bringing the object nearer; again, the accommo¬ 
dation is often defective in the higher degrees of M., and, 
as the fully correcting lens requires full accommodation, 
it will lead to over-straining if this function be weakened, 
and so cause discomfort, if nothing worse. For these two 
reasons the rule is to give, for near work, a glass which 
will diminish the myopia, but not fully correct it. Glasses 
for near work are seldom needed unless M. exceed 3 D. 

Let M. be 7 D., then r will be at 14 cm. (p. 40) from the 
eye. If a glass be required with which the patient shall 
be able to read at 30 cm., or which shall remove r from 14 
cm. to 30 cm.— i. e., shall leave the patient with M. 3 D., 
we must correct the difference between 7 D. and 3 I) (7 D. 


342 


CLINICAL DIVISION. 


— 3D. =4 D.); a concave lens of 4 D. will make rays 
from 30 cm. diverge as if they came from 14 cm. But 
even this partial correction may diminish the images so 
much that, if vision be imperfect from extensive choroidal 
changes, reading at the increased distance will be difficult, 
and the patient will prefer to bring the object nearer again 
at the expense of his accommodation, and will thus be in¬ 
convenienced instead of bettered; it is, therefore, often 
advisable, even for partial correction, to order a weaker 
lens than is optically correct. 

Preponderance of the external over the internal recti, 
insufficiency of convergence, p. 332, if not cured by par¬ 
tially correcting glasses, may be treated by division of the 
external rectus of one or both eyes, but not until after an 
effort has been made to strengthen convergence by means 
of properly regulated prismatic exercise. For this pur¬ 
pose the patient fixes his gaze upon a point of light 20 
feet away, while the strongest prisms, bases out, with which 
the patient can fuse the light are placed in a spectacle 
frame (Fig. 123). After regarding the light a few mo- 


Fig. 123. 



ments, the eyes being still fixed upon it, the prisms are 
raised and the convergent effort relaxed; after a few 
moments the prisms are again lowered before the eyes, and 
this alternate lowering and raising of the prisms, and the 
consequent stimulation and relaxation of the convergence, 
persisted in for five minutes. These exercises should be 
repeated three times daily, and the strength of the prisms 
increased as the patient is found to be able to fuse higher 





























REFRACTION AND ACCOMMODATION. 343 


ones. By this procedure the power of adduction is fre¬ 
quently carried to 100° within a few weeks, with great 
relief to the asthenopia. Marked benefit will be also 
obtained by the internal administration of tincture of nux 
vomica, especially if the drug be given until symptoms 
of its physiological action appear. Tenotomy of the ex¬ 
ternal rectus muscle may always be done when there is a 
marked divergent squint, even if the squint be variable. 
Prismatic spectacles (p. 26), the bases of the prisms being 
toward the nose, are occasionally serviceable for reading in 
cases of slight muscular insufficiency. By deflecting the 
entering light toward their bases, Fig. 16, the prisms give 
to rays from a certain near point a direction as if they 
came from a greater distance, and thus lessen the need for 
convergence of the optic axes. The prisms may be com¬ 
bined with concave lenses. 

M. may also be caused by an increase of the curvature, 
or of the refractive power of the media, myopia of curva¬ 
ture. Thus in conical cornea (p. 149) the curvature of the 
central part of the cornea is increased— i. e., its focal length 
shortened, and the principal focus of the lens-system lies 
in front of the retina, often very far in front, without any 
change of place of the parts at the back of the eye. M., 
usually of low degree, often comes on in commencing senile 
cataract (p. 198) from a shortening of the focal length of 
the crystalline lens, doubtless due to increase of refractive 
index (p. 17). M. is sometimes simulated in H., and actual 
M. increased by needless and uncontrollable action of the 
ciliary muscle—spasm of accommodation. Removal of the 
lens has lately been extensively practised in the treatment 
of myopia of high degree, 15 D. and upward. The pub¬ 
lished results of operations show that this treatment is of 
advantage in preventing the progressive stretching of the 
tunics of the eye, and in making vision more comfortable. 

The lens is best removed by discission, without removal 


344 


CLINICAL DIVISION. 


of any of the lens matter unless glaucomatous symptoms 
supervene. An interesting fact in regard to the extraction 
of the lens in myopia is that the amount of reduction in 
the refraction of the eye is much greater than one would 
a priori expect. Thus, it is found at times that after 
removal of the lens the refraction has changed as much as 
15 to 20 D., whereas one would expect but a reduction of 
10 D., the supposed refractive power of the crystalline lens. 

Hypermetropia (H.). 

H. is optically the reverse of M. It is one of the most 
common conditions we have to treat. The eyeball is too 
short, axial hypermetropia , so that when the accommoda¬ 
tion is relaxed the retina lies within the principal focus of 
the eye. As rays from an object within the principal focus 
of a convex lens emerge from the lens divergent, Figs. 10 
and 13, so pencils of rays leaving a hypermetropic eye are 


Fig. 124. 



Hypermetropia. Parallel rays focussed behind retina. Rays already 
convergent focussed on retina. 


divergent, Fig. 127; and, conversely, only rays already 
convergent can be focussed on the retina. H. always 
dates from birth, and does not afterward increase, except 
slightly in old age. But it may diminish and even give 
place to M. by elongation of the eye. Iu Fig. 124 the 
curved line representing the retina is in front of f, com¬ 
pare Fig. 115. Parallel rays will, after passing through 
the lens, meet the retina before focussing and form a blurred 
image, while divergent rays, meeting the retina still further 



REFRACTION AND ACCOMMODATION. 345 


from their focus, will form an even worse image, compare 
Fig. 116; hence neither distant nor near objects will be 
seen clearly. But by using accommodation the focal length 
can be shortened until the focus falls upon the retina Fig. 
125, and distant objects are then seen clearly; and addi- 


Fig. 125. 



Ilypermetropia corrected by accommodation. Parallel rays focussed 

on retina. 


tional accommodation will give also distinct vision of near 
objects, compare Fig. 116. A little consideration will show 
that the competence of the ciliary muscle to give these re¬ 
sults will depend in any given case (1) on the degree of 
advancement of the retina in front of f— i. e., on the de¬ 
gree of shortening of the eye; and (2) on the strength of 
Acc.— i. e., on the extent to which the focal length of the 
lens can be altered. 

Fig. 126. 



Ilypermetropia corrected by a convex lens whose focus coincides with the 

virtual focus of the retina. 

The same result may be gained by placing a convex lens 
in front of the eye, instead of using the accommodation. In 
a given case, Acc. being relaxed, let the ray, a, Fig. 126, 




346 


CLINICAL DIVISION. 


on leaving the eye diverge from the axis as if it proceeded 
from a point v. f., compare Fig. 13, 25 cm. behind the 
cornea. If the ray a', parallel with the axis, pass through 
a convex lens, l, of 25 cm. focal length held close to the eye, 
it will be made to converge toward this same point, and, 
therefore, in accordance with § 12 (p. 22) will be focussed 
on the retina at a. 

Fig. 127 may be taken for a section of a very highly 
hypermetropic eye, the rays emerging from which are 
divergent. The image formed on the retina of a hyper¬ 
metropic eye is smaller than that of the same object placed 
at the same distance from a normal eye (p. 30). 


Fig. 127. 



Course of the rays emerging from a hypermetropic eye. 


In old age the refractive power of the crystalline lens 
seems normally to diminish, and, therefore, an eye origin¬ 
ally emmetropic becomes unable to focus parallel rays on 
the retina; this condition causes slight acquired liyperme- 
tropia, and begins at the age of sixty-five. 

Symptoms and Results of H. The direct symptoms 
are due to insufficiency of the accommodation ; for distinct 
vision of any object, whether near or distant, requires Acc. 
proportionate to the degree of shortening of the eye, and 
the absolute power (amplitude) of Acc. is not increased in 
H., at any rate not enough to meet the demand. 

If H. is slight or moderate and Acc. vigorous, no incon- 



REFRACTION AND ACCOMMODATION. 347 


venience is felt either for near or distant vision. But if 
Acc. have been weakened by disease or ill-health, or have 
failed with age, the patient will complain that he can no 
longer see near objects clearly for long together; that the 
eyes ache or water, or that everything “swims” or be¬ 
comes “dim” after reading or sewing for a short time, 
accommodative asthenopia . There is not usually much com¬ 
plaint of defect for distant objects. Many slight or mod¬ 
erately H. patients find no inconvenience till twenty-five 
or thirty years of age, when Acc. has naturally declined 
by nearly one-half. Women are often first troubled after 
a long lactation, and other persons after prolonged study 
or desk-work, or when suffering from chronic exhausting 
diseases. Children often complain of watering, blinking, 
and headaclie, rather than of dimness (see also p. 279). 

In very high degrees of H., as a large part of the Acc. 
is always needed from childhood upward for distant sight, 
even the strongest effort does not suffice to give clear 
images of near objects, which consequently such a person 
never sees well. Such patients often partially compensate 
for the dimness of near objects by bringing them still 
nearer, thus enlarging the visual angle and increasing the 
size of the retinal images (p. 30). This symptom may be 
mistaken for M., but can be distinguished by the want of 
uniformity in the distance at which the patient places 
his book, and by his being often unable, at any dis¬ 
tance whatever, to see the print easily or to read fluently. 
In the highest degrees even distinct distant vision is not 
constantly maintained, the patient often being content to let 
his accommodation rest except when his attention is roused. 

As age advances, a point is reached, even in moderate 
degrees of H., at which Acc. no longer suffices even for 
distant, and much less for near vision. Such persons tell 
us that they early took to glasses for near work, but add 
that lately the glasses have not suited, and that they are 


348 


CLINICAL DIVISION 


now unable to see clearly either at long or short distances. 
Ophthalmoscopic examination shows no change except H., 
and suitable convex glasses at once raise distant vision to 
the normal. Occasionally photophobia, conjunctival irri¬ 
tation, and redness are present in H., but the first-named 
symptom is less common than in M. (see p. 278). The most 
important indirect result of H. is convergent strabismus (see 
p. 368). 

Treatment. The treatment of H. consists in removing 
the necessity for overuse of Acc. by prescribing convex 
spectacles, which, in proportion to their strength, supply 
the place of the increased convexity of the crystalline lens 
induced by Acc. In theory, the whole Acc. ought to be 
corrected by glasses in every case, and the eye be rendered 
emmetropic. But in practice we find it often better to 
give a weaker glass, at least for a time. 

If Acc. in a H. eye be in abeyance (paralyzed by atro¬ 
pine) vision for distant objects will be distinct only if the 
rays pass through a convex lens, held in front of the eye, 
whose focus coincides with the virtual focus of the retina 
(p. 345, Fig. 126). The strength of this lens is the measure 
of the H.; thus the patient has H. 2 D. if a convex lens 
of 50 cm. focal length is necessary for this purpose. 

But if Acc. be intact, then, as it has constantlv to be 
used for distant sight, the patient is often unable to relax 
it fully, when a corresponding convex lens is placed in 
froat of the eye; he will relax only a part, and this part 
will be measured by the strongest convex lens with which 
he can see the distant types clearly. That part of the H. 
which can be detected by this test is called “ manifest” 
(m. H.). The part remaining undetected, because corrected 
by the involuntary use of Acc., is latent (1. H.). The sum 
of the m. H. and 1. H. is the total H. 

Now, most H. people can habitually use some Acc. for 
distance, and a corresponding excess for near vision with- 


REFRACTION AND ACCOMMODATION. 349 


out inconvenience, and hence the full correction of H. is 
by no means always needful, or even agreeable to the 
patient. In many cases the correction of the m. H. is 
enough to relieve the asthenopic symptoms, at any rate 
for a considerable time; but we often find that after wear¬ 
ing these glasses for some weeks or months the symptoms 
return, and a fresh trial will show a larger amount of m. 
H., which must then again be corrected by a correspond¬ 
ing increase in the strength of the glasses. This process 
may have to be repeated several times until after a few 
months the total H. becomes manifest and may be cor¬ 
rected. This method is most suitable for adults in whom 
the use of atropine to paralyze Acc., and allow the imme¬ 
diate estimation of the total H., is inconvenient or impos¬ 
sible ; or for whom the glasses which correct the total H., 
as estimated by the ophthalmoscope, without atropiniza- 
tion are found, if ordered at once, to be inconveniently 
strong. But for children there is seldom any gain and 
often no little inconvenience from following this gradual 
plan; with them the better way is to estimate the total 
H., and to order glasses slightly (about 1 D.) weaker than 
that amount. 

To Examine for H. 1. For m. H. Note the patient’s 
vision for distant types at 6 m., then hold in front of his 
eyes a very weak convex lens (-{- 0.5 D.), and if he sees 
as well, or better, with it, go to the next stronger lens, 
and so on until the strongest has been found which allows 
the best attainable distant vision; this lens is the measure 
of the m. H. 

2. For H. (total). The easiest and most certain plan is 
to direct the patient to use strong atropine drops (F. 33) 
three times a day for at least two days, and then to test his 
distant vision with convex glasses. As in (1), the strongest 
lens which gives the best attainable sight is the measure of 
the H. 


350 


CLINICAL DIVISION. 


Ophthalmoscopic Tests. 3. The image of the disk 
seen by the indirect method becomes smaller when the lens 
is withdrawn from the eye, Fig. 119, B. 

4. The shadow test is described at p. 75. 

5. By direct examination an erect image is seen at what¬ 
ever distance the observer be from the patient (p. 74). The 
oberver may learn, as stated at p. 74, to estimate H. with 
almost as great accuracy with a refraction ophthalmoscope 
as by trial lenses, and this plan, like the shadow test, is 
extremely valuable with children who are too young or too 
backward to give good answers. The total, or nearly the 
total H. may often be found in this way without atropine 
if the examination be made in a dark room, for then Acc. 
is generally quite relaxed, however persistently it may 
have acted when the patient was able to look attentively 
at objects in the light. The objective estimates, 4 and 5, 
however, are more easily made after the use of atropine. 

The next question is, whether the glasses are to be worn 
always, or only when Acc. is specially strained— i. e., in 
near work. They are to be worn constantly (1) whenever 
we are attempting to cure a squint by their means; (2) in 
all cases of high H. in children, wdiether with or without 
strabismus. But patients who come under care for the 
first time, as young adults, in whom the H. is, as a rule, 
of moderate or low degree, may generally be allowed to 
wear them only for near work. Elderly persons require 
two pairs—one for distance, neutralizing the m. H., the 
other stronger, neutralizing the presbyopia also, for near 
work (p. 361) ; the use of the former may, however, be left 
to the patient’s choice. 

Hypermetropia is frequently associated more or less with 
high degrees of esophoria, and the oculist will labor in 
vain who corrects the ametropia without considering the 
muscle error. In most cases the constant wearing of as 
nearly a full correction as can be borne with comfort will 


REFRACTION AND ACCOMMODATION. 351 


be efficacious in establishing a more normal muscle-balance ; 
in other instances, however, further measures will be neces¬ 
sary. 

Unlike in exophoria, in which the Editor has had most 
excellent results follow strengthening convergence by 
means of prismatic exercise, in esophoria, exercise for the 
development of the externi has been without beneficial 
effect. On the other hand, however, he has found a par¬ 
tial correction of the esophoria by means of prisms, bases 
out, incorporated into the lenses which correct the hyper- 
metropia, to be most efficacious in this class of cases. In 
addition to this, tincture of belladonna, hyoscyamus, or 
some of the other sedatives should be given in as large 
doses as can be borne, to diminish the spasm or abnormal 
contraction of the adductors. 

Astigmatism (As.). 

In the preceding cases (M. and H.) the refracting sur¬ 
faces of the eye (the front of the cornea and the two sur¬ 
faces of the lens) have been regarded as segments of spheres, 

All the rays of a cone of light which issue from a round 
spot and pass through such a system are, neglecting 
“ spherical aberration,” Fig. 9, equally refracted, and 
meet one another at such a single point—the focus of the 
system. For if such a cone of incident light be looked 
upon as composed of a number of different planes of rays, 
situated radially around the axis of the cone, the rays situ¬ 
ated in any plane, say the vertical, will, after passing 
through the lens-system, meet behind it at its focus, while 
those forming any other plane, as the horizontal, will meet 
at the same point. 

But let the curvature, and, therefore, the refractive power 
of one of the media, for instance, the cornea, be greater in 
one meridian, say the vertical, than in the horizontal, then 
the vertical-plane rays will meet at their focus, while the 


352 


CLINICAL DIVISION. 


hoizontal-plane rays at the same distance, not having yet 
met, will, if received on a screen, form a horizontal line 
of light. If the intermediate meridians had regularly 
intermediate focal lengths, they would form at the same 
place lines of intermediate lengths, and the image of the 
round spot of light, if caught on a screen at this distance, 
would form a horizontal oval. To a retina receiving such 
an image, the round point of light would appear drawn 
out horizontally. Such an eye is called astigmatic, be¬ 
cause unable to see a point as such; all round points 
appearing drawn out more or less into lines. 

A little reflection will show that in the same case, at the 
focal point of the hoizontal-plane rays, the rays of the 
vertical plane will already have met and crossed, and 
that the image at this point will form a vertical oval. 

If the screen be placed midway between these two 
extreme points, the image will be circular, but blurred, 
because the vertical-plane rays will have crossed and 
began to separate, while the horizontal ones will not yet 
have met, and each set will be equally distant from its 
focus. The meridians of the astigmatic medium which 
refract most, shortest focus, and least, longest focus, are 
the principal meridians. The distance between their foci is 
the focal interval, and represents the degree of astigmatism. 

The astigmatism of the eye may be regular or irregular. 
In regular astigmatism, the meridians of greatest and least 
refractive power, “ principal meridians,” are always at 
right angles to each other; and every meridian is nearly 
a segment of a circle. Of the principal meridians, the 
most refractive, the one with shortest focal length, is, as a 
rule, vertical, or nearly so, and the least refractive, there¬ 
fore, horizontal, or nearly so. The cornea is the principal 
seat of this asymmetry. The crystalline lens, however, 
is also astigmatic to a less degree, and its meridians of 
greatest and least curvature are usually so arranged as 


REFRACTION AND ACCOMMODATION. 


353 


in some degree to neutralize those of the cornea; it thus 
partially corrects the corneal error. Corneal astigmatism 
is often caused by operations for cataract or iridectomy (p. 
209). 

Regular astigmatism is corrected by a lens which equal¬ 
izes the refraction in the two principal meridians. Such 
a lens must be a segment of a cylinder, instead of, like an 
ordinary lens, a segment of a sphere. Rays traversing a 
cylindrical lens in the plane of the axis of the cylinder are 
not refracted since the surfaces of lens in this direction are 
parallel; but rays traversing it in all other planes are re¬ 
fracted more or less, and most in the plane or meridian at 
a right angle with the axis. 

Irregular astigmatism may be caused either by irregu¬ 
larities of the cornea, arising from ulceration, inflamma¬ 
tion, or conicity 1 (p. 149); or by various conditions of the 
crystalline lens, such as differences of refraction in its 
various sectors, tilting or lateral dislocation of the lens, so 
that its axis no longer corresponds, as it should nearly do, 
with the centre of the cornea. Irregular astigmatism 
causes much distortion of the ophthalmoscopic image, 
especially when the object lens is moved from side to side. 
It is seldom much benefited by glasses. 

Returning to regular astigmatism , it will be seen that 
the optical condition of the eye depends upon the position 
of the retina in respect to the focal interval. In the fol¬ 
lowing diagram, Fig. 128, let the most refractive meridian 
be vertical, and its focus be called a, the least refracting 
meridian horizontal and its focus b. The astigmatism is 
here represented as caused by altered position of the retina 
in different planes, instead of by altered curvature of the 

1 There can be little doubt from clinical observation with a refraction oph¬ 
thalmoscope, that corneal As. is often complicated by the curvature of each 
meridian being naturally more or less elliptical instead of circular, and this 
without any tendency toward “couical cornea,” as commonly understood. 

23 


354 


CLINICAL DIVISION. 


cornea in different planes, the diagram being, of course, 
only intended to aid the comprehension of the principle. 

1. Let a fall on the retina (1, Fig. 128), and b, therefore, 
behind it. There is E. in the vertical meridian, and there¬ 
fore H. in the horizontal meridian; this is simple H. As. 

2. Let b fall on the retina, 2, Fig. 128, and a in front of 
it. The horizontal meridian is, therefore, E., and the ver¬ 
tical meridian M.; simple M. As. 3. Let a and b both 
lie behind the retina (3, Fig. 128). There is H. in both 
meridians, but more in the horizontal than the vertical 
meridian ; compound H. As. 4. a and b are both in front 


Pig. 12S. 



of the retina (4, Fig. 128). There is M. in both meridians, 
but more in the vertical than the horizontal; compound 
M. As. 5. a is in front of the retina and b behind it (5, 
Fig. 128). There is M. in the vertical and IT. in the hori¬ 
zontal meridian; mixed As. 

The general symptoms of As. resemble those caused by 
the simpler defects of refraction; but attention to the 
patient’s complaints, and to the manner in which he uses 
his eyes, will, in the higher degrees, often give the clue to 
its presence. Low degrees, especially of simple TI. As., 
often give rise to no inconvenience till rather late in life. 
As. is most commonly met with in connection with H., be¬ 
cause H. is so much more common than M. But it is said to 
occur with greater relative frequency in M., when, if com¬ 
plications be present, it may, if not of high degree, be 



REFRACTION AND ACCOMMODATION. 355 


readily overlooked unless specially sought for. The higher 
grades of As. cause much inconvenience, no objects being 
seen clearly; and spherical glasses, though of use if the 
As. be compound, are nearly useless if it be simple. As. 
is always to be suspected if, with the best attainable spher¬ 
ical glasses, distant vision is less improved than it ought to 
be, supposing of course that no other changes are present 
to account for the defect. No definite rule can be laid 
down as to the degree of defect which should raise the sus¬ 
picion of As.; indeed, in the higher degrees of even simple 
M. and H., acuteness of vision is often below normal (pp. 
271 and 337). It is possible that in young persons with 
vigorous accommodation the astigmatism of the cornea is 
partly corrected by the ciliary muscle acting unequally on 
the different meridians of the lens, and that the seemingly 
greater frequency of astigmatism in the presbyopic is due 
to the impairment of this power. 

As. may be measured either by trial with glasses, by the 
shadow test (p. 75), or by ophthalmoscopic estimation (p. 
78) of the refraction of the retinal vessels in the two chief 
meridians. A comparatively easy qualitative test is found 
in the apparent shape of the disk, which, instead of being 
round, is more or less oval. In the erect image the long 
axis of the oval corresponds to the meridian of greatest re¬ 
fraction. and is, therefore, as a rule, nearly vertical, Fig. 129. 

In the inverted image, Fig. 130, the direction of the oval 
is at right angles to the above, provided that the object lens 
be nearer than its own focal length to the eye. As. is sus¬ 
pected when, in the erect image, an undulating retinal 
vessel appears clear in some parts and indistinct in others, 
an appearance which may be taken for retinitis if the ex¬ 
amination be confined to the erect image. It may be imi¬ 
tated by looking at a wavy line through a cylindrical lens. 

In the indirect examination the shape of the disk changes 
on withdrawing the lens from the patient’s eye. It will be 


356 


CLINIC A L DI VISION. 


remembered that in M. the image increases as the lens is 
withdrawn (p. 334, 2), that in E. its size remains the same, 


Fig. 129. 


Fig. 130. 


Erect image of disk in astigma¬ 
tism, with meridian of greatest re¬ 
fraction nearly vertical. (Wecker 
and Jaeger.) 


The same disk seen by the 
indirect method. (Wecker 
and Jaeger.) 




while in H. it diminishes, Fig. 119. Thus, in a case of 
simple M. As. in the vertical meridian, that dimension of 
the disk which is seen through the vertical meridian will 
enlarge on distancing the lens; from being oval horizon¬ 
tally when the lens is close to the eye, it becomes first 
round and then oval vertically on withdrawing the lens. 
In the other forms of As. the same holds true; the image 
enlarges either absolutely as in M. As., or relatively as in 
H. As., in the direction of the most refracting meridian. 

The subjective tests for As. are very numerous, but all 
depend on the fact that if an astigmatic eye look at a 
number of lines drawn in different directions, some will be 
seen more clearly than others. The form of this test is not 
a matter of great consequence, provided that the lines are 
clear, not too fine, and are easily visible with about half the 





REFRACTION AND ACCOMMODATION. 357 


normal V. at from 3 m. to 6 m. The forms resembling a 
clock-face with bold Roman figures at the ends of the radii 
are very convenient, and I prefer the pattern recommended 
by Mr. Brudenell Carter (see Appendix) to any other that 
I have used. On this face are three parallel black lines 
separated by equally wide white spaces, and which collec¬ 
tively form a “ hand” that can be turned round into the 
positions of best and worst vision. 

The easiest case for estimation is one of simple H. As., 
in which the eye is under atropine. Many cases of simple 
M. As. are almost as easy to test. In a given case let the 
eye be E. in the vertical meridian, and H. in the horizon¬ 
tal. With Acc. paralyzed, rays refracted by the vertical 
meridian will be accurately focussed on the retina, while 
the focus of those refracted by the horizontal meridian will 
be behind the retina, Fig. 128, 1, and consequently form 
on it a blurred image. Now the rays which strike in the 
plane of the vertical meridian are those which come from 
the borders of horizontal lines; hence the patient under 
consideration will see the lines at a distance of 3 m. to 6 
m. quite clearly when the “hand” is horizontal, except 
their ends, which will be blurred. The rays which strike 
in the plane of the horizontal meridian are those which 
proceed from the sides of vertical lines, and as this meri¬ 
dian is hypermetropic, the lines in the “ hand,” when 
placed vertically, will be indistinct, except their ends, 
which will be sharply defined. We now leave the “ hand” 
vertical, and test the refraction for the lines in this position 
(i. e., for the horizontal meridian) in the ordinary way and 
find, e. g., that with -j-2 D, they are seen most clearly, 
though not perfectly. On substituting for the spherical 
glass, -j- 2 D. cylinder with its curvature horizontal— i. e., 
its axis vertical, the lines of the hand and all the figures 
on the clock will be seen perfectly; the vertical lines and 
figures will be seen through the horizontal meridian cor- 


358 


CLINIC A L I) I VISION. 


rected by the cylinder lens, and the horizontal figures 
through the unaided vertical meridian, the rays which 
pass through the cylinder in this meridian not being re¬ 
fracted. 

In a case of simple M. As. in the vertical meridian the 
lines of the “ hand” will be dull or invisible when hori¬ 
zontal, while when vertical they will be clear. On trial a 
concave cylinder will be found, which with its curvature 
vertical, axis horizontal, makes the lines of the hand quite 
clear when horizontal, and all the figures quite plain. 

The cases of compound and mixed As. are less easily 
dealt with by this test. It is generally best to find, in the 
usual way, the spherical glass which gives the best result 
for the distant types, and then, arming the eye with this 
glass, to test for As., with the clock-face and cylindrical 
lenses, as in the simple cases described above. As the 
letters of Snellen’s distant types are made up of lines run¬ 
ning in various directions, As. can be very well tested with 
these, and in actual practice the clock-face is not necessary 
in most cases. 

We may use, instead of a cylindrical glass, a narrow slit 
in a round plate of metal which can be placed in the direc¬ 
tion of either of the chief meridians, the spherical glass 
being then found with which, in each meridian, the patient 
sees best. One chief meridian may be ascertained by find¬ 
ing the direction of the slit which gives the best sight with 
the spherical glass chosen in the preliminary examination, 
and the other meridian by finding the glass which gives 
the best result with the slit at a right angle to the former 
direction. 

Another method, that of Javal, consists in making the 
patient highly myopic for the time being, by means of a 
convex lens, unless he be myopic already ; then accurately 
finding his far point for the least myopic meridian, and 


REFRACTION AND ACCOMMODATION. 359 


lastly finding the concave cylinder which is needed to re¬ 
duce the opposite meridian to the same refraction. 

Ophthalmoscopic estimation and retinoscopy, however, 
save much time, especially in mixed As. If As. he meas¬ 
ured by direct ophthalmoscopic examination, we may re¬ 
member that the axis of the correcting cylinder will be 
parallel to the vessel used as a guide to either of the chief 
meridians; and that in retinoscopy the same axis is par¬ 
allel to the edge of the shadow. Thus if a vertical vessel 
be clearly seen with -(- 2 D., the horizontal vessels being 
best seen with no lens, retinoscopy will also show H. 2 D. 
for the shadow moving horizontally— i. e., with a vertical 
edge, and the patient will choose a cylinder of -f 2 D. 
with its axis vertical— i. e., its curvature horizontal be¬ 
cause the horizontal meridian of his eye has H. 2 D., the 
vertical meridian being E. 

Whatever means be employed, the degree of As. is ex¬ 
pressed by the difference between the glasses chosen for 
the two chief meridians; or by the cylindrical lens which, 
added to the chosen spherical, gives the best result for the 
lines or the distant types. When cylindrical glasses are 
ordered the whole of the astigmatism should be corrected. 
It is not usually necessary to correct astigmatism of less 
than 1 D. ; but exceptions to this rule are not uncommon, 
some patients deriving marked relief from the correction 
of lower grades. 

Vision is often defective in As., and in the high degrees 
we are often obliged to be content with a very moderate 
improvement at the time of examination. This may some¬ 
times be explained by the retina never having received 
clear images— i. e., never having been accurately practised 
(p. 271); V. in such cases often improves after proper 
glasses have been worn for some months. In other cases 
irregular As. is the cause of the defect. Much also de¬ 
pends on the intelligence of the patient; some persons are 


360 


CLINICAL D T VIS TON. 


far more appreciative of slight changes in the power, or in 
the direction of the axis of the cylinder than others, and 
this apart from the absolute acuteness of sight. 

Unequal refraction in the two eyes (Anisometropia). It 
is common to find that one eye has more H., more M., or 
more As. than its fellow; or that one is normal while the 
other is ametropic. When the difference is not more than 
is represented by 1.5 D., and Y. is good in both (see p. 
271), the refraction may with advantage be equalized by 
giving the glasses which correct each eye, and the devel¬ 
opment of divergent squint may sometimes be prevented 
by the increased stimulus to binocular vision thus given. 
But equalization is seldom possible if the difference be 
greater, though, especially in myopic cases, advantage is 
sometimes gained by partial equalization. On the other 
hand, some patients, probably those who do not possess 
binocular vision, will not permit even a partial equaliza¬ 
tion. When no attempt is made to harmonize the eyes, 
the spectacles ordered should suit the less ametropic eye. 
Often, when one eye is E. and the other M., each is used 
separately for different purposes, and both remain perfect; 
but if one be As. or very H., it is generally defective from 
want of use. 

In anisometropia the Editor has found that hyperphoria 
is present in all cases in which the difference in refraction 
between the eyes is at all marked, even when associated 
with a moderate degree of esophoria or exophoria; conse¬ 
quently if binocular vision be aimed at, a partial correc¬ 
tion of the hyperphoria should always be attempted by 
incorporating vertical prisms into the correcting lenses. 

Contrary to what might be expected, anisometropia is 
seldom, if ever, corrected by unequal action of the two 
ciliary muscles. 


REFRACTION AND ACCOMMODATION. 3G1 


Presbyopia (Pr.). 

Presbyopia, old sight, often called “ long-sight,” is the 
result of gradual recession of p, which takes place as life 
advances, and which causes curtailment of the range or 
amplitude of Acc. (p. 50). From the age of ten (or ear¬ 
lier) onward, p is constantly receding from the eye. When 
it has reached 9” (22 cm.)— i. e., when clear vision is no 
longer possible at a shorter distance than 22 cm., Pr. is 
said to have begun. The standard is arbitrary, 22 cm. 
having been fixed by general agreement as the point be¬ 
yond which p cannot be removed without some inconveni¬ 
ence, the point where age begins to tell on the practical 
efficiency of the eyes unless glasses are worn. In the nor¬ 
mal eye this point is reached soon after forty, and the rate 
of diminution is so uniform that the glasses required to 
bring p to 22 cm. may often, if necessary, be determined 
merely from the patient’s age. But as there are exceptions 
to this rule, even for normal eyes, and as allowance has to 
be made for any error of refraction (H. or M.), it is unsafe 
in practice to rely upon age except as a general guide. 

The slow failure of Acc., causing Pr., depends upon senile 
changes in the lens, which render it firmer and less elastic, 
and therefore less responsive to the action of the ciliary 
muscle. There can be little doubt, however, that failure 
of the ciliary muscle itself, or of its motor nerves, also 
forms an important factor in those cases where Pr. comes 
on earlier or more quickly than usual; but it is a curious 
fact that in these cases of premature Pr. the mobility of 
the iris is not affected.. 

As Pr. depends on a natural recession of the near point, 
it occurs in all eyes, whether their refraction be E., M., or 
H. In M., however, Pr. sets in later than in a normal 
eye, because for the same range of Acc. the region is always 
nearer than in the normal eye. In H., on the contrary, 


CLINICAL DIVISION. 


362 


Pr. is reached sooner than is normal, because for the same 
range of Acc. the region is always further than in the nor¬ 
mal eye. Thus in an E. eye a power of Acc. = 4.5 D. 
gives a range from r = infinity to p — 22 cm. (the focal 


Fig. 132. 



Region and range of Acc. in E., M., and H. Range of Acc. diminishes 

with age. 



The numbers along the top show the range of Acc. in dioptres from infinity 
(oo ), or beyond it in H., to 15 D. The numbers beyond oo represent dioptres 
of Acc. necessary to correct H. Observe that the range of Acc. is always the 
same at the same age, though its region varies with the refraction of the eye. 

length of 4.5 D., see p. 50)— i. e., Pr. is just about to begin ; 
at set. 50, Acc. = 2.5 D., and p = 40 cm. (the focal length 
of 2.5 D). In a case of M. 3 D., set. 50, the range being 
= 2.5 D., the region of Acc. lies between 33 cm. (the r for 
this eye) and 18 cm. (—focal length of 3 2.5, or 5.5 

D.); Pr. has not yet began. In a case of H 3 D. with 
4.5 D. of Acc. 3 D. of it are used in correcting the H.— 
t. e., in bringing r to infinity, and only 1.5 D. remains; p 
















REFRACTION AND ACCOMMODATION. 36-3 


is therefore at 66 cm. — focal length of 4.5— 3, or 1.5 
D.), and a -f- lens of 3 D. is needed to bring p to 22 cm.; 
there is Pr. = 3 D. The only cases in which Pr cannot 
occur are in M. of more than 4.5 D. Thus if M. = 7 D., 
r is at 14 cm., and though, with advancing years, p will 
recede to 14 cm., it cannot go further, cannot reach 22 cm.; 
the patient, who never could see at a greater distance than 
14 cm., has simply lost the power to see at a shorter dis¬ 
tance. Fig. 132 shows these facts in a graphic manner. 

Treatment. Convex spectacles are found, by the aid* 
of the Table at p. 364, with which the patient can read at 
22 cm.. 

In practice it is always advisable to examine for H. or 
M., by taking the distant vision, and trying the patient 
for m. H. and M. If m. H. be found, arm the patient 
with the glass which neutralizes it and makes him E., and 
then add the convex glass that should, by the Table, be 
required to bring p to 22 cm. If M. be found, subtract 
its amount from the corresponding convex glass. 

As Pr. is usually associated with H., M., or As., it is 
often necessary that the ametropia should be corrected 


Fig. 133. 



also; this necessitates the wearing of two sets of glasses. 
The inconvenience and annoyance necessitated by this have 
been largely overcome by the bifocal slips, so called, which 
are small segments of lenses cemented upon the distance 
lenses. As these slips are somewhat unsightly, and as many 
patients object to wearing them for cosmetic reasons, Har¬ 
lan has substituted a small lens made of flint glass for the 
bifocal, and by sinking it into the distance lens made of 



364 


CLINICAL DIVISION 


crown glass gained the increased refraction necessitated by 
the Pr. bv means of the higher index of refraction of the 

%J o 

flint glass. 

In prescribing for Pr. we must often order rather less 
than the full correction. For instance, if Acc. be almost 
entirely lost, p is practically removed to r, and the glass 
which will bring p to 22 cm. will also bring r to the same, 
or nearly the same point, and the patient will be able to 
see clearly only just there. Now, 22 cm. is too near for 
sustained vision, and such patients often prefer a glass 
which gives them a near point of from 30 to 40 cm. (12" 
to 16"), though in choosing it they sacrifice the power of 
easily reading very small print. The difficulty experi¬ 
enced by these patients in reading with glasses which give 
p — 22 cm. depends on the unaccustomed strain thereby 
thrown on the internal recti; and it may be removed or 
lessened by adding to the convex glasses, prisms, with their 
bases toward the nose, Fig. 16; or by decentring the or¬ 
dinary convex lenses inward, Fig. 17. 


Presbyopia Table for Emmetropic Eyes. 


/ 

Age. 

Distance of p. 

Pr. expressed by the lens 
necessary to bring p to 
22 cm. or 9". 

Cm. 

Inches. 

Dioptres. 

Paris inch 
scale. 

40 . 

22 

9 

0 

0 

45 . 

28 

11 

+1 

+ 3 V 

50 . 

43 

17 

2 

1 

TIT 

55 . 

67 

27 

3 

1 

Tl? 

CO . 

200 

72 

4 

1 

65 . 

Infinity. 

4.5 

* 

70 . 

Acquired H = 1 D. 

5.5 

** 

75 . 

“ H = 1.5 I). 

6 

* 

80 . 

“ H = 2.5 D. 

7 





















CHAPTER XXL 


STRABISMUS AND OCULAR PARALYSIS. 

Strabismus exists whenever the two eyes are not, as 
they ought to be, directed toward the same object. The 
eye is “directed toward” an object when the image is 
formed on the most sensitive part of the retina, the yellow 
spot; the straight line joining the centre of this image 
with the centre of the object is the “ visual axis.” 1 The 
action of the ocular muscles is normally such as to keep 
both visual lines always directed to the object under re¬ 
gard, binocular but single vision being the result. Al¬ 
though each eye receives its own image, only one object is 
perceived by the sensorium, because the images are formed 
on parts of the retinae which “ correspond ” or are “ iden¬ 
tical ” in function— i. e., which are so placed that they 
always receive identical and simultaneous stimuli. 

But if, owing to faulty action of one or more of the 
muscles, one eye deviate, and the visual lines cease to be 
directed toward the same object, the image will no longer 
be formed on the y. s. in both eyes. In one of them it 
must fall on some other and non-identical part of the 
retina, and the result is that two images of the same object 

1 We sometimes meet with an apparent squint, either external or internal. 
The optic axis of the eye passes from a point rather to the inner side of the 
y. s. through the centre of the cornea, and forms a small angle (“ angle o”) 
with the visual axis, the line which joins the y. s. to the object looked at, and 
which commonly cuts the cornea rather within its centre. As we judge of 
the apparent direction of a person’s eyes by the centres of his cornese— i. e., by 
the optic axes, a slight apparent outward squint will be produced if the angle, 
a, be, as in many hypermetropic eyes, larger than usual, and an apparent 
convergent squint if, as in myopia, it be smaller. Apparent squint is always 
slight, and the screen test described in the text gives a negative result. 

(365) 


366 


CLINICAL DIVISION. 


are seen (Diplopia, p. 379). In Fig. 134 y is the y. s. in each 
eye, and the visual line of the R. eye (the thick, dotted 
line) deviates inward ; hence the image of the object (ob.) 
which is formed at y in the L. eye, will in the R. eye fall 
on a non-identical part to the inner side of y. ob. will be 
seen in its true position by the L. eye To the R. eye, 
however, it will appear to be at F. ob., because the part 


Fig. 134. 



Shows the position of the double images in diplopia from convergent or 
crossed strabismus. The images are homonymous, or correspond in position 
to the eyes. 

of the R. retina which now receives the image of ob. was 
accustomed, when the eye was normally directed, to receive 
images from objects in the position of F. ob .; and in con¬ 
sequence of this early habit F. ob. is the position to which 
every image formed on this part of the retina is refered. 



STRABISMUS AND OCULAR PARALYSIS. 367 


Hence, if the eye deviate toward its fellow (convergent 
squint—as in Fig. 134). the false image will seem to the 
squinting eye to be in the opposite direction; the image 
(F. ob .) for the R. eye being referred to the patient’s R., 
and that for the L. eye (ob.') to his L., in convergent or 
crossed strabismus the double images correspond in position 
to the eyes, or are homonymous. Similar reasoning will 


Fig. 135. 


Position of double images in divergent strabismus. 


The images are crossed. 



show that if the eye deviate away from its fellow, Fig. 135, 
divergent squint, the position of the double images must be 
reversed, and the image belonging to the R. eye appear to 
be to the left of the other; hence, in divergent squint the 
double images are crossed. 



368 


CLINICAL DIVISION. 


Since the image of ob. in the squinting (R) eye is formed 
on a portion of the retina, more or less distant from the 
most perfect part (the y. s.), it will not appear so clear or 
so bright as the image formed at the y. s. of the sound (or 
“working”) eye; it is called the “false” image, that 
formed in the working eye being the “true” one. The 
greater the deviation of the visual line (i. e., the greater 
the squint) the wider apart will be the two images appear 
and the less distinct will the “ false ” image be. 

The y. s. (y) of the squinting (R.) eye will receive an im¬ 
age of some different object lying in its visual line (shown 
by the thick dotted line); this image, if sufficiently marked 
to attract attention, will be seen, and will appear to lie upon 
the image of ob. seen by the “working” (L.) eye; two 
equally clear objects will be seen superimposed. But, as 
a rule, only one of these images is attended to, the percep¬ 
tion of the other being habitually suppressed, even sooner 
than that of the “ false image” (p. 269); the suppressed 
image always belongs to the squinting eye. 

Squinting is not always accompanied by double vision 
because: (1) if the deviation be extreme, the false image 
is formed on a very peripheral part of the retina, and is so 
dim as not to be noticed; conversely, the less the squint 
the more troublesome is the diplopia, when present; (2) as 
already mentioned (p. 270), after a time the “ fake image ” 
is suppressed; or the eye may have been very defective 
before the squint came on. 

When a squint is well marked there is no difficulty in 
identifying the squinting eye as the one which is misdi¬ 
rected when an object is held up to the patient’s attention : 
in most cases the patient always squints with the same eye, 
but a few persons can squint with either indifferently— alter¬ 
nating squint. Nor is there often any doubt as to whether 
the squint is internal (convergent) or external (divergent)— 
i. e.. whether the axis of the squinting eye crosses that of 


STRABISMUS AND OCULAR PARALYSIS. 369 


its fellow between the patient and the object lie looks at, 
or crosses it beyond this object, or even positively diverges 
from it; upward or downward squint, though less common, 
is almost as evident. But to prove beyond doubt which is 
the squinting eye, direct the patient to look at a pencil 
held up in the middle line at about 18" from his face, and 
with a card or piece of ground-glass cover the apparently 
sound, or “ working” eye; the squinting eye will at once 
move so as to look at, or “fix ” the pencil, proving that it 
had previously been misdirected. If the sound eye be 
watched behind the screen it will be seen to squint as soon 
as the affected eye “ fixes ” the object; this is known as the 
secondary squint , and its direction is the same as that of 
the original or primary squint. Thus if the primary squint 
be convergent, the secondary will also be convergent. In 
squint from overaction, or from mere disuse, of one mus¬ 
cle, the secondary and primary deviations are equal, but 
in paralytic squint the secondary often exceeds the pri¬ 
mary. If the squinting eye retain full range of movement— 
i. e ., move in companionship with its fellow in all direc¬ 
tions, the squint is termed concomitant , in contradistinction 
to paralytic; hence in every case of squint it is necessary 
to test the mobility of the eyes. It is also important to 
note whether the squint is constant or only occasional ( peri¬ 
odic ]). 

It was, until lately, usual to measure the squint, when 
necessary, by means of a scale placed on the lower lid and 
graduated in such a way as to indicate in lines (or mm.) 
the amount of deviation. The centre of this scale, marked 
zero, is placed over the centre of the lid, and therefore 
corresponding to the centre of the pupil if there be no 
squint; the number which corresponds to the centre of the 
pupil of the squinting eye gives the linear measurement 
of the deviation. A more accurate and rational method, 
introduced by Landolt, and known as the angular method, 

24 


370 


CLINICAL DIVISION. 


determines the size of the angle between the positions of 
the visual axis of the eye when squinting and when prop¬ 
erly directed. In Fig. 136, L is the squinting left eye of the 


, Fig. 136. 



Angular measurement of squint. (After Landolt.) 

patient placed at the centre of a perimeter ; Lx, the diree- ' 
tion of its visual axis; L Ob, the direction its visual axis 
should have; Ob an object, as far off as possible, at which 
the patient is to look ; x a small candle flame which the 
observer, stationed close behind the perimeter, moves along 
the arc until he sees its image reflected from the centre of 
the squinting cornea; the size of the angle X L Ob, read 
off on the perimeter, is nearly the same as that of the angle 
of deviation. A convenient method of estimating the 



STRABISMUS AND OCULAR PARALYSIS. 371 


amount of angular deviation, introduced by Hirschberg, 
consists in the observation of the corneal reflex from a 
candle or ophthalmoscope mirror held about a foot from 
the eye. When the eyes are properly directed, the position 
of the reflex occupies the centre of the pupil in each eye 
unless the angle a be very large. If the eye squint inward, 
the reflex falls on the outer side of the centre. The pupil 
being of moderate width, 3 mm., if— 

1. The reflex be nearer centre of p. than edge, deviation is <10° 

2. “ “ at edge of p. deviation is . . 12°—15 

3. “ 11 midway between edge of p. and edge of 

C. deviation is . . . . .25 

4. “ “ at edge of C. deviation is . . .45 

Strabismus may arise from any one of the following mus¬ 
cular conditions: (1) over-action; (2) weakness following 
over-use; (3) disuse of an eye whose sight is imperfect; 

(4) stretching and weakening of a tendon after tenotomy ; 

(5) from paralysis of one or more of the muscles. 

Fuchs 1 has shown that considerable variations occur in the 
attachments of the recti and obliqui to the sclerotic. Such 
variations in the attachment and power of the muscles probably 
operate as predisposing causes of the squint in groups 1, 2, and 3. 

1. Over-action of the internal recti gives rise to the con¬ 
vergent squint of hypermetropia. The association of con¬ 
vergent squint with hypermetropia was first observed by 
Bonders and explained by him in the following way : The 
relationship between accommodation and convergence is 
a remarkably close one; most people are unable to accom¬ 
modate without, at the same time, converging their visual 
axes. Moreover a given degree of accommodation carries 
with it a constant degree of convergence. Hypermetropes 
are obliged to use their Acc. to see even distant things 
clearly; they are generally unable to dissociate this Acc. 

1 Fuchs: Graefe’s Arch., xxx., abstracted in Ophth. Review, vol. iv. 
1885, 143. 


372 


CLINICAL DIVISION. 


from its usual amount of convergence. So that in fixing 
an object at 50 cm. distance, requiring Acc. of 2 D., a 
hypermetrope of 2 D. uses 4 D. of Acc. in order to sec it 
clearly. But 4 D. of Acc. in the normal eye goes with 
convergence for a point at 25 cm. distance. Such a per¬ 
son, therefore, has to do two things at once, to look at an 
object distant 50 cm., and to make his visual axes meet at 
25 cm. The former he does by directing an eye— e. g., the 
R.—to the object 50 cm. off; the latter by converging the 
visual axis of the L. so that it meets that of the R at 25. 
cm. In this case the L. eye will squint inward, but both 
internal recti will act equally in bringing about the con¬ 
vergence, and both eyes will use as much accommodation 
as a pair of normal eyes would do at 25 cm. In most cases 
the squint always affects the same eye, and this is gener¬ 
ally accounted for by some original defect of the eye itself, 
such as a higher degree of H. or As., or a corneal opacity; 
but people who see equally well with each eye often squint 
with either indifferently (alternating squint). This ex¬ 
planation, though it accounts for a large number of the 
cases of concomitant convergent squint, is not a complete 
one—squint is not present in every case of H.; it is not 
always most marked in the highest degree of squint; and 
some cases of convergent squint occur in E. and M. 
Schweigger believes that a want of muscular balance is 
the main cause of strabismus, and that in convergent 
squint the internal recti preponderate over the external; 
in H. there is a congenital tendency toward preponderance 
of the internal recti, and in myopia of the external. Han¬ 
sen Grut thinks that the preponderance is dependent on 
the innervation of the muscles. In cases of lono- standing 
the range of movement of the squinting eye is often defi¬ 
cient. 

This “concomitant” convergent strabismus generally 
comes on early in childhood, as soon as the child begins 


STRABISMUS AND OCULAR PARALYSIS. 373 


to look attentively and use Acc. vigorously in regarding 
near objects. In examining eases we shall be struck by 
finding that (a) in some the squint is noticed only when Acc. 
is in full use—that it appears and disappears under observa¬ 
tion, according as the child fixes its gaze on a near object 
or looks into space, periodic squint. 

Periodic squint often occurs, chiefly when the child is nervous 
or tired; several patients have assured me that their occasional 
convergent squint scarcely ever came on except when eating. 

(■ b ) In others the squint is constant, but is more marked 
during strong Acc.; (c) it is constant, invariable, and of 
high degree; (d) in most cases patients who see equally 
well with each eye often squint with either indifferently, 
alternating squint . The squint causes diplopia, and to 
avoid this inconvenience patients for the most part soon 
learn to ignore (or “ suppress” ) the image formed in the 
squinting eye, the result usually being that this eye be¬ 
comes very defective. This power of suppressing the false 
image is learned most easily in very early life. In alter¬ 
nating squint no permanent suppression occurs, and con¬ 
sequently both eyes remain good. 

The squint sometimes disappears spontaneously as the 
child grows up; this might be explained by an increased 
power of dissociating Acc. from convergence, or by a 
diminution of H. from elongation of the eye, or by a gen¬ 
eral tendency in all persons, and of this there is other 
evidence, to weakening of the internal recti with ad¬ 
vancing age. 

Treatment of Convergent Hypermetropic Squint. 
(a) If the squint be periodic, it can be cured by the con¬ 
stant use of spectacles which nearly correct total H. 

(6) The same is true in some cases where the squint, 
though constant, is alternating or varies in degree, being 
greater during Acc. for near than for distant objects. 


374 


CLINICAL DIVISION. 


(c) If the squint be constant in amount and of some 
years’ standing, operation is usually necessary. As the 
squinting eye is then usually very defective (p. 269), the 
removal of the deformity is the chief object of the opera¬ 
tion, binocular vision being comparatively seldom restored. 
Hence, in view of the tendency to spontaneous cure already 
mentioned, I think it better, as a rule, not to operate on 
children below the age of six, especially as in younger chil¬ 
dren we cannot always tell whether or not the squint be 
still periodic. The most rational treatment for children 
under four, when glasses may often be began, is to cover 
the eyes alternately with a blind, for some hours daily, to 
ensure each eye being alternately used; but this plan can 
seldom be carried out. 

In older persons orthoptic training, as suggested by 
Javal, should be essayed. As it is necessary for this pur¬ 
pose that the patient should be conscious of double images, 
the squinting eye must be exercised with a prism base 
downward, and a candle-flame as visual object. After 
diplopia has been obtained a large sheet of cardboard is 
held upright between the eyes, and the patient told to 
regard a candle-flame several metres in front of him. The 
screen is now removed, and an attempt made to fuse the 
images by means of a stereoscope, into which + S. 6 D. 
lenses have been introduced in place of the usual prism. 
The distance between the pictures in the stereoscope is then 
diminished until the patient is just able to fuse them. 

When operation is decided upon, it is a safe rule to divide 
only one internal rectus at a sitting. At the end of a few 
weeks, if the squint still be considerable, the operation is 
performed on the other eye. 1 

Muscular asthenopia or actual divergence is very likelv 

1 Regulations for operating in convergent strabismus in relation to its 
degree have been laid down by various authors; recently by Hirschberg: 
Centralblatt fur Augenlieilkunde, 1S96, p. 5. 


STRABISMUS AND OCULAR PARALYSIS. 


375 


to come on some years later if both tendons are needlessly 
divided. It is safer to leave slight convergence than to 
run this risk. See also Divergent Strabismus. 

2. Divergent squint from weakness of the internal recti, 
insufficiency of convergence, depends upon relaxation or ab¬ 
solute weakening of the internal recti. It is most common 
in M., but is not infrequent in II., and even in E. This 
form of squint sets in gradually, with difficulty in using 
the eyes for long together for reading, etc., the internal 
recti not being able to keep up convergence, muscular 
asthenopia; in this stage it may often be detected by 
covering one eye while the patient looks attentively at 
some near object, for the covered eye will diverge when 
thus excluded, latent divergent squint, though in the interest 
of binocular vision convergence may be maintained for a 
short time when both eyes are open. The position of the 
eyes may be more exactly ascertained by the use of Mad¬ 
dox’s rod. Latent divergent strabismus is sometimes a 
temporary condition due to over-use of the eyes, or want 
of general vigor, in young adults. Anything which lessens 
the importance of binocular vision predisposes to divergent 
squint— e. g., defective sight of one eye from anisometropia. 
Latent divergence is extremely apt to pass gradually into 
manifest permanent divergent squint. In this form of 
strabismus the eye can be moved into the inner can thus, 
even in extreme cases, by making the patient look side¬ 
ways, though not by efforts at convergence, and it is thus 
but rarely that the cases simulate paralysis. Tenotomy 
of the external rectus, and even “advancement” of the 
weakened muscle, are often needed. In slight cases the 
symptoms are sometimes quite cured by wearing prisms 
with their bases toward the nose; but, as far as I know, 
one can seldom predict success with any certainty from 
their use. One of the most troublesome features in mus¬ 
cular asthenopia is its great variability with the patient’s 


37 6 


CLINICAL DIVISION. 


state of health ; the symptoms sometimes disappear entirely 
in a bracing climate, returning as soon as the patient comes 
back to his less invigorating home air. 

3. Strabismus from disuse is also nearly always diverg¬ 
ent, depending as it does on relaxation of the internal 
rectus. It occurs in cases where convergence is no longer 
of service, as when one eye is blind from opacity of the 
cornea, or other cause, or where the refraction of the two 
eyes is very different (p. 360). Tenotomy of the external, 
with or without advancement of the internal rectus, may 
be performed. 

4. Stretching and weakening of the internal rectus after 
division of its tendon for convergent squint may give rise 
to divergence, simulating that caused by paralysis of the 
internal rectus. The caruncle in these cases, however, is 
generally much retracted, and this, together with the his¬ 
tory of a former operation, will prevent any mistake in 
diagnosis. Such a squint can always be lessened, and 
often quite removed, by an operation for readjustment or 
advancement of the defective muscle. 

5. Heterophoria.—The tests for heterophoria, or latent 
squint, have already been given (see p. 51). Sometimes, 
however, the use of the Maddox rod will not be necessary 
to ascertain the existence of these deviations, for the sim¬ 
ple holding of a colored glass before one eye will be suffi¬ 
cient to remove the inducement to binocular vision, and 
any latent squint will at once become manifest. The 
images may also be separated by a prism. Thus, if a prism 
of 10° be placed with its base up before one eye, any lateral 
separation indicates the amount of exophoria or esophoria; 
crossed diplopia indicating the former, homonymous diplo¬ 
pia the latter (modified Graefe test). 

In obtaining the distance, as well as the near muscle- 
balance, it is essential that as much of any existing devia¬ 
tion be made manifest as possible. It suggested itself to 


STRABISMUS AND OCULAR PARALYSIS. 377 


the Editor that it would be well to endeavor to measure 
the deviation that the eye undergoes when it is screened 
off in the ordinary refraction-test, whilst the other eye fixes 
the test-card sharply in the endeavor to obtain the best 
visual acuity. To accomplish this, the vision of the right 
eye is first obtained, the left eye being obscured by an 
opaque metallic disc. This done, the right eye is obscured 
by the disc and the left eye made to regard the chart. So 
soon as the vision of this eye has been obtained, instead 
of removing the shield from before the right eye and per¬ 
mitting the patient to bring the eyes into a state of paral¬ 
lelism by the unconscious desire for fusion necessary for 
binocular vision, the patient is told to regard a bright 
electric light placed on a level with the line of test-letters 
that he has just read, and but a few inches from it, the 
right eye still being covered. The Maddox rod is then 
lowered before the left eye, the patient’s attention called to 
the streak, the disc quickly removed from before the right 
eye, and the patient requested to give the relative positions 
of the light and the streak. Any deviation, lateral or 
vertical, is at once measured by means of the rotary 
prisms that are in position before the eyes. The method 
is a rapid and satisfactory one, and has frequently revealed 
the existence of insufficiencies that were not rendered man¬ 
ifest by the usual method of employing the rod-test. The 
same method has been utilized as a part of every refrac¬ 
tion-test. After the refraction of one eye has been deter¬ 
mined, the correcting lenses are allowed to remain in posi¬ 
tion back of the metallic disc that is placed before the 
eye, while the other eye is examined. So soon as this is 
accomplished the patient is requested to transfer his gaze 
to the light, a red Maddox rod is dropped before the eye, 
and the shield is removed from its fellow, when the slightest 
deviation will be made manifest and can be accurately 
determined by the prisms. This last procedure has been 


378 


CL INTO A L 1)1 VISION. 


of great value in many intricate cases, and has often 
directed the attention to the true muscle-error. It is abso¬ 
lutely essential for this test that the point of light at which 
the patient is requested to transfer his gaze from the letters 
on the test-chart should be bright and close to the row of 
letters that he has just read, else the excursions of the eye 
will be too great, and so great a movement required that 
impulses will be generated in the deviating eye that will 
defeat the purposes of the test. This has been accom¬ 
plished by means of a simple apparatus devised by 
Messrs. Wall & Ochs, of Philadelphia, which consists ot 
an electric light shaded by a Thorington chimney, 
attached to a metal rod placed a few inches in advance of 
and to the side of an ordinary test-card. The light may 
be adjusted to correspond to any row of letters on the 
chart, so that in any event the eye will not have to make 
a greater movement than the few inches from the letters to 
the light. The light that illuminates the chart is also 
electric, and, in common with the light for the muscle-test, 
is so arranged that it may be operated by the surgeon at 
the patient’s side by means of switches. The moment the 
refraction is ascertained the light in the chimney is turned 
on and that for the chart off, so that a perfect contrast is ob¬ 
tained and the double images invited to appear and persist. 

As a result of the muscle-tests made in this manner, 
hyperphoria was observed to exist in many cases in which 
it did not reveal itself to the usual tests with the Maddox 
rod, or to the disassociation of images accomplished by the 
use of prisms; and furthermore it was ascertained that 
muscle-balance is present when the phorometer shows at 
5 m. 2° or 3° of homonymous diplopia, and from 2° to 4° 
of crossed diplopia at the reading distance. Under such 
conditions abduction will be found to equal 8° or 9° and 
adduction from 18° to 25°, the ratio that exists in the 
majority of well-balanced eyes. 


STRABISMUS AND OCULAR PARALYSIS. 379 


6. Paralytic squint. The deviation is caused by the 
unopposed action of the sound muscles. When the palsied 
muscle tries to act, the eye fails, in proportion to the weak¬ 
ness, to move in the required direction. In many cases 
there is only slight paresis, and the resulting deviation is 
too little to be objectively noticeable; but in such cases 
the diplopia, as mentioned already, is very troublesome, 
and it is for this symptom that the patient conies under 
care. Further, in these slight cases the symptoms often 
vary with the effort made by the patient. In paralysis of 
the third nerve the several branches are often affected in 
different degrees, and the strabismus and diplopia are then 
complex. When paralysis of any ocular muscle is of long 
standing, secondary contraction of the opponent seems 
sometimes to occur, and complicates the symptoms. Fur¬ 
ther difficulty in diagnosis is occasionally caused by the 
sound yoke-fellow 1 of the paralyzed muscle acting too 
much, in obedience to efforts made by the latter; when 
this happens the squint will sometimes, even when both 
eyes are uncovered, affect the sound instead of the par¬ 
alyzed eye— i. e., it will alternate. 

12. Diplopia (double sight) is almost always a result of 
squint, and is usually most troublesome when the deviation 
is so slight as to be hardly perceptible. Diplopia caused 
by squint is, of course, binocular, and disappears when 
one eye is covered. Uniocular diplopia, double sight with 
one eye, however, often occurs in commencing cataract, and 
sometimes in healthy but astigmatic eyes; it has also been 
met with in some cases of cerebral tumor. In the former 
cases it has a physical cause in the crystalline lens (see 
Cataract); in the latter it must depend upon some psychical 
change. 

1 Yoked or conjugate muscles are the muscles of opposite eyes which act 
together in producing lateral and vertical movements— e. g., the internal 
rectus of one eye acts with the external rectus of the other in movement of 
the eyes to the R. or L. 


380 


CLINICAL DIVISION. 


To find out what defect of movement is causing binoc¬ 
ular diplopia, darken the room, and ask the patient to 
follow with his eyes a lighted candle, held about 6' from 
him, moved successively into different positions, and to 
describe the relative places of the double images in each 
position. Ascertain which of the two images belongs to 
each eye by placing before one eye a strongly colored glass, 
or by covering one eye and asking which image disappears. 
In many cases the image formed in the squinting eye, the 
“ false ” image, is less bright or distinct, and this difference 
gives a valuable means of distinguishing the sound from 
the affected eye; but the patient does not always notice a 
difference between the two images, and there may then be 
difficulty in proving which eye is at fault. The patient’s 
replies may be recorded on such a diagram as Fig. 120; 
other radii may, of course, be added for intermediate posi¬ 
tions ; the false image is marked by the dotted line, the 
true one by the unbroken line. With this graphic repre¬ 
sentation of the candle as it appears to the patient, we can 
deduce from the apparent position of the false image what 
movements of the corresponding eye are at fault, and, con¬ 
sequently, which muscle or muscles are defective. It is 
essential that the patient should not move his head during 
the examination, and that he remain throughout at the 
same distance from the candle. Remember that, in the 
extreme lateral movements, the nose eclipses one image. 
When the double images are very wide apart— i. e., when 
there is much squint, the patient often fails to notice the 
false image. 

For the diagnosis of a case of diplopia it is often suffi¬ 
cient to ask in which directions the double sight is most 
troublesome, and how the images appear in respect to 
height, lateral separation, and apparent distance from the 
patient. Chapter XXI. 

The most common forms of paralytic squint are due to 


STRABISMUS AND OCULAR PARALYSIS. 381 


affection, separately, of the external rectus (sixth nerve), 
superior oblique (fourth nerve), or of one or all of the 
muscles supplied by the third nerve, internal superior and 
inferior recti, inferior oblique, levator palpebne. 1 

Paralysis of the external rectus (sixth nerve ) causes a con¬ 
vergent squint, from preponderance of the internal rectus, 
which, except in the slightest cases, is usually very notice 
able. Movement straight outward is impaired, and if the 
paralysis be complete, the eye cannot be moved outward 
beyond the middle line of the palpebral fissure. There is 
homonymous diplopia; the two images, when in the hori¬ 
zontal plane, are upright and on the same level; the dis¬ 
tance between them increases as the object is moved toward 
the paralyzed side, but it diminishes, or the images even 
coalesce, in the opposite direction. Thus in paralysis of 
the left external rectus, Fig. 137, uppermost figure, the 
images separate more as the object is moved to the patient’s 
left, but approach one another, and finally coalesce, as it 
is moved over to his right. In slight cases the diplopia 
ceases when the patient looks at an object a few inches off, 
but reappears when he gazes straight forward at a distant 
object. In the upper part of the field the false image is 
sometimes lower, and in the lower part of the field higher 
than the true one. I have many times noticed that the 
pupil is larger in the affected eye than in the other, a con¬ 
dition which we should not expect. 

In paralysis of the superior oblique (fourth nerve) there 
is either no visible squint, or only a slight deviation upward 
and inward. But when the eyes are directed below the 
horizontal, very troublesome diplopia arises from the de¬ 
fective downward and outward movement, and loss of rota¬ 
tion of the vertical meridian inward, to which the lesion 
gives rise. In downward movements, especially downward 

1 In 77 cases of paralysis of a single oculomotor nerve I found the third 
nerve affected in 3L cases, the fourth in 9, and the sixth in 37. 


382 


CLINICAL DIVISION. 


and toward the paralyzed side, the eye remains a little 
higher than its fellow; in trying to look straight down, 
inferior rectus and superior oblique, the unopposed action 
of the inferior rectus carries the cornea somewhat inward, 
convergent squint, and at the same time rotates the ver¬ 
tical axis outward, while the cornea remains on a rather 
higher level than its fellow; in following an object from 
the horizontal middle line down-outward, it will be seen 
that the vertical meridian of the cornea does not, as it 
should, become inclined inward. 

In many cases, however, the slight defects of movement 


Fig. 137. 



Chart showing position of double images, as seen by the patient in paralysis 
of L. external rectus and R. superior oblique. 

caused by paralysis of the superior oblique are not clearly 
marked, and the diagnosis has to be based on the charac¬ 
ters of the diplopia. In all positions below the horizontal 
line the false image is below the true one, and displaced 
toward the paralyzed side (homonymous); thus, if the R. 
muscle be at fault, the false image will be below and to 
the patient’s R., Fig. 137, arrow-head figure; further, it is 
not upright, but leans toward the true image. The differ¬ 
ence in height between the images is greatest in movements 



STRABISMUS AND OCULAR PARALYSIS. 383 


toward the sound side; the lateral separation is greater 
the further the object is moved downward ; the leaning of 
the false image is greatest in movements toward the par¬ 
alysed side. When the patient looks on the floor— i. e., 
projects the images on to a horizontal surface, the false 
image seems nearer to him than the true one. The images 
are always near enough together to cause inconvenience, 
and as the diplopia is confined to, or is worst in, the lower 
half of the field, the half most used in daily life, paralysis 
of the superior oblique is very annoying, especially in 
going up or down stairs, in looking at the floor, counting 
money, eating, etc. 

Paralysis of the third nerve, when complete, causes 
ptosis, loss of inward, upward, and downward movements, 
loss of accommodation, and partial mydriasis, well-marked 
divergent strabismus from unopposed action of the external 
rectus, and crossed diplopia. The downward and outward 
movement, with rotation of the vertical meridian inward 
effected by the superior oblique, remains. The mydriasis 
is much less than that produced by atropine. In many 
cases the paralysis is incomplete, affecting some branches 
(and muscles) more than others, and the symptoms are 
then less typical. Isolated paralysis of a single third-nerve 
muscle is rare. 

There is a peculiar form of intermittent paralysis of the 
third nerve, known as ophthalmoplegic migraine , which 
occurs in the young, and is associated with headache and at 
times with vomiting. 

Peculiarities of paralytic strabismus. 1. If a patient 
suffering— e. g. y from paresis of one external rectus—look 
at an object distant about two feet, and the sound eye be 
then covered by holding a card or a piece of ground-glass 
before it, the paralyzed eye will make an attempt, more or 
less successful according to the degree of palsy, to look at 
the object. The movement affected will call for a greater 


384 


CLINICAL DIVISION. 


effort than if the sixth nerve were healthy, and as the eye 
muscles always work in pairs, the same effort will be trans¬ 
mitted to the internal rectus of the healthy eye. The latter 
will, in consequence, describe a larger movement than the 
paralyzed eye— i. e., the secondary squint will be greater 
than the primary (p. 369). This test is sometimes of use in 
distinguishing which is the faulty eye in cases where the 
squint is slight and the patient unable to distinguish be¬ 
tween the false and true images (p. 380). 2. Giddiness is 
often present when the patient walks with the sound eye 
closed. This symptom depends on an erroneous judgment of 
the position of surrounding objects, which is caused by the 
weakened muscle not being able to achieve a movement 
of the eye corresponding in magnitude to the effort made. 
It is absent when both eyes are open, and when the par- 
alyzed eye is covered. It often helps us more than does 
the former symptom in determining which is the faulty 
eye; but it varies much in severity in different cases, and 
may be quite absent. Patients with ocular palsy often 
keep one eye closed, nearly always the paralyzed one , to 
avoid diplopia. 

Paralysis of the ocular muscles is seldom symmetrical; 
in the rare cases where it is so the disease is usually intra¬ 
cranial. In uncomplicated symmetrical “ ophthalmoplegia 
externa ” (paralysis of all the external muscles, the iris and 
ciliary muscles escaping) the disease is usually nuclear, 
while in cases of symmetrical disease of oculomotor nerve- 
trunks both external and internal muscles are paralyzed; 
but even in nuclear ophthalmoplegia the disease may spread 
forward and attack the centres for the iris and ciliary 
muscle, and the differential diagnosis may then be exceed¬ 
ingly difficult to make. In the later stages of nuclear 
ophthalmoplegia other cranial nerves (especially the optic 
and fifth) may be involved, and symptoms of spinal or 
bulbar disease be present. 


STRABISMUS AND OCULAR PARALYSIS. 385 


The fibres of the third and fourth nerves arise from a column 
of nerve cells beneath the floor of the aqueduct of Sylvius. It 
is probable that the centre for accommodation lies in front, with 
that for the sphincter of the pupil next, the centres for the 
other muscles following, but their exact order is not yet known. 
The nuclei of the internal and external recti are in communica¬ 
tion by the posterior longitudinal fibres, so that their combined 
action in lateral movements of the eyes is secured. There is a 
centre for the convergence of the eyes close to the middle line. 

Affections of the Internal Muscles of the Eyeball. 

Physiological Outline. The nerves of the iris are— a, the 
third for contraction of the pupil; b, the cervical sympathetic 
for its dilatation ; and c, the fifth supplying sensory fibres. The 
sympathetic fibres ( b ) come from the cord probably through the 
anterior root of the second dorsal nerve, and reach the eye— 

(1) through the Gasserian ganglion from the carotid plexus; 

(2) through the lenticular ganglion from the cavernous plexus ; 

(3) it is stated that sympathetic (dilator) fibres accompany the 
fifth nerve directly from its origin. The filaments of the fifth 
(c) form (1) the long root of the lenticular ganglion (which gives 
off the short ciliary nerves); (2) the long ciliaries, two or three 
in number, independent of the ganglion. The human iris con¬ 
tains a circular (sphincter) unstriped muscle close to the pupil, 
and a dilator muscle consisting of a thin layer of plain mus¬ 
cular tissue passing from the sphincter to the circumference of 
the iris. 

If the third nerve be divided or paralyzed, the pupil dilates 
moderately (never extremely) and becomes motionless to light 
and accommodation, and accommodation is lost. Of contrac¬ 
tion of pupil and spasm of accommodation from irritation of 
the nerve, we have little clinical knowledge; but experimental 
stimulation of the nerve produces those effects. Section or 
paralysis of the cervical sympathetic causes some contraction 
of pupil and destroys its power of dilating when shaded; stimu¬ 
lation of it, or of the anterior root of the second dorsal (in 
monkeys, Ferrier), causes well-marked dilatation, which, how¬ 
ever, is less than that due to atropine; irritation of the skin, 


25 


386 


CLINICAL DIVISION. 


stimulating the dilator nerve, causes slight, momentary dila¬ 
tation. 

All the drugs which act upon the iris act on the ciliary muscle 
too, but the iris is affected sooner, for a longer time, and by 
weaker solutions than the ciliary muscle. 

Atropine, and all the mydriatics except cocaine, dilate the 
pupil and paralyze the accommodation; the effect of atropine 
on the pupil in old people is often, and in children sometimes, 
very small; the mydriasis of atropine is greater than that due 
to paralysis of third nerve, but is somewhat increased if the 
third nerve be cut. It acts in old-standing paralysis of iris 
(third nerve) and of cervical sympathetic, but in both condi¬ 
tions the mydriasis is apt to be rather less than full; the my¬ 
driasis is said to be rather increased by stimulating the long 
ciliary nerves, and diminished by cutting the fifth, owing to 
the sympathetic fibres contained in it. Atropine dilates the 
pupil of a freshly excised (rabbit’s) eye, and of the eye of an 
animal bled to death, and it acts a little if put on to the human 
eye very soon after death. From the above it is inferred that 
atropine acts directly upon the muscular fibres, paralyzing 
them, and not upon the nerve fibres. Atropine does not act 
upon the iris of birds containing striped muscle. 

Eserine and pilocarpine contract the pupil and cause spasm 
of accommodation ; they have the same action in long-standing 
paralysis of iris (third nerve), and after section of the third 
nerve and of the sympathetic; they have very little effect if 
atropine have been used, but they immediately overcome the 
mydriasis of cocaine. Eserine and pilocarpine, therefore, 
probably act directly on the muscular fibres, stimulating them. 

Cocaine dilates the pupil, but does not prevent its action to 
light and accommodation, and has but little action on the ciliary 
muscle; hence it does not act by paralyzing either the third- 
nerve fibres or the muscular fibres. It causes further dilatation 
of a pupil dilated by atropine or by section of third nerve ; while 
it does not dilate the pupil if the cervical sympathetic have been 
cut or paralyzed for some little time. It also causes retraction 
of the eyelids and contraction of the superficial bloodvessels of 
the eye. Hence, cocaine probably acts by stimulating the sym¬ 
pathetic nerve-fibres. Consult Michael Foster’s Physiology; 


STRABISMUS AND OCULAR PARALYSIS. 387 


Ferrier, Functions of Brain, second edition, and Proc. of Roy. 
Soc., 1883; Gowers, Diseases of Nervous System , vol. i.; Jessop, 
Proc. of Roy. Soc., 1885-86; Marshall, Lancet, 1885, ii. 286; 
Author’s own cases. 

The following forms of paralysis, or altered innervation, 
of iris and ciliary muscle agree tolerably with the above 
physiological facts. 

A. Pupil alone. 1. Paralysis of dilatation : pupil in good 
light, equal to or smaller than the other ; but when shaded, 
dilates little if at all, so that in dull light it is much the 
smaller, paralytic miosis; accommodation not affected. This 
uncommon condition is, when well marked, generally one¬ 
sided, and due to paralysis of cervical sympathetic by pres¬ 
sure— e. g., by aneurism or tumor, or enlarged glands at 
the root of the neck, or injury to the brachial plexus; it 
should, therefore, always lead to careful examination. A 
degree of miosis and non-dilatability of pupils is common 
in old age. 2. The opposite state, spasmodic mydriasis, is 
very rare as a permanent symptom, though temporary, 
varying dilatation of one pupil is sometimes seen in young 
or neurotic persons. Persistent spasmodic mydriasis is said 
to occur in the early (irritative) stage of lesions, which 
afterward produce paralytic miosis ;* in this state we should 
expect the pupil, though dilated, to act both to light and 
to accommodation, as after cocaine. 3. Of paralytic my¬ 
driasis, paralysis of third-nerve fibres of the sphincter 
muscle, without paralysis of accommodation we know but 
little, 2 except in a slight degree as a residue after recovery 
from the double condition (paralysis of sphincter iridis and 
ciliary muscle), the pupil often not recovering so well or 
so soon as the accommodation. Compare the action of the 
drugs above given. 4. Paralysis of iris, iricloplegia, with- 

1 Gowers: Diseases of Nervous System, i. 152. 

2 See several cases reported by the author in Ophth. Hospital Reports, vol. 
xi. iii. pp. 260-264. 


388 


CLINICAL DIVISION. 


out defect of accommodation, usually affects only the action 
to light, reflex iridoplegia, the associated action remaining. 
It occurs as a very early symptom in locomotor ataxy, 
sometimes without any other symptoms of that disease, and 
should always lead to full investigation. It is probably 
due to degeneration in that part of the nucleus of the third 
which presides over the reflex action of the pupil. 

b. Paralysis of accommodation alone (cyclop legia) is often 
seen after diphtheria. It is often incomplete, and the pupils 
are usually unaffected; but if the cyeloplegia be complete 
there is sometimes mydriasis. In ataxy there is occasion¬ 
ally cyeloplegia with a pupil active to light. Accommoda¬ 
tion is sometimes quite lost without any alteration of pupil 
in what is spoken of as premature presbyopia, but this is 
not called cyeloplegia, not being supposed to be paralytic. 

c. Ciliary muscle and iris affected. 1. Cyeloplegia ivith 
mydriasis; loss of accommodation; pupil dilated to about 
5 mm. and motionless; the ordinary condition in complete 
paralysis of third nerve. It is now and then seen without 
failure of any other part of the third nerve, and the pupil 
may then be quite widely dilated. When an old person gets 
paralysis of the third, the pupil is often very little dilated. 
2. Total iridoplegia, with cyeloplegia, ophthalmoplegia in¬ 
terna , accommodation lost; pupil motionless to reflex and 
associated stimuli, and of medium size; this is sometimes a 
later stage of A (4), but it may be primary, due to nuclear 
disease; the paralysis, both of iris and ciliary muscle, is 
often incomplete. In paralysis of sixth nerve the pupil of 
the paralyzed eye is often rather larger than that of the 
other. 

Causes of Ocular Paralysis. It is convenient to 
separate the external and mixed forms from those in which 
only the internal muscles are involved, since the local lesions 
are, as a rule, different in the two groups. 

Paralysis of the third, fourth, or sixth nerve may be the 


STRABISMUS AND OCULAR PARALYSIS. 389 


result of tumors or other growths in the orbit, but in such 
cases, as a rule, the paralysis forms only one among other 
well-marked local symptoms. In the vast majority of 
uncomplicated ocular palsies we are quite unable to de¬ 
cide, either from the state of the eye or the orbital parts, 
whether the lesion be in the orbit or within the cranium. 
Meningitis, morbid growths, and syphilitic periostitis at the 
base of the skull, or involving the sphenoidal fissure, often 
cause ocular palsy, seldom confined to one nerve ; aneurism 
of the internal carotid in the cavernous sinus occasionally 
does so. Syphilitic gumma of the nerve-trunk is probably 
the most common cause of single paralysis; the intracranial 
portion of the nerves is known to be often the seat of such 
growths, but small neural gummata probably occur also on 
the orbital part of the nerves. Injuries to the head often 
cause ocular paralysis ; the paralysis is usually noticed very 
soon after the accident, and is probably always a sign of 
fracture of the base involving the middle fossa, or of some 
part of the walls of the orbit. Direct damage to, or thick¬ 
ening subsequent to fracture near the pulley, seems to 
account for some cases of traumatic paralysis of the supe¬ 
rior oblique. Pain in the temple or front of the head is 
very common in ocular palsies due to periostitis and gum¬ 
mata. In certain cases neither the symptoms nor history 
enable us to locate the seat or prove the cause of the par¬ 
alysis; the term “ rheumatic ” is often applied to such 
cases, on the assumption that the palsy is peripheral and 
caused by cold—that it is in fact to be compared to 
peripheral paralysis of the facial nerve; no doubt some 
of these are in reality syphilitic. Paralysis, usually of 
short duration and affecting only one nerve, is not uncom¬ 
mon at an early stage of locomotor ataxy. Ophthalmo¬ 
plegia externa generally sets in slowly, is bilaterally sym¬ 
metrical and permanent; it usually indicates sclerotic 
disease of the nerve centres, often caused by syphilis; 


390 


CLINICAL DIVISION. 


but it is sometimes caused by tumor centrally placed, or 
by symmetrical gummata on nerve-trunks. Occasionally 
ocular palsies are “ functional,” or occur in company with 
symptoms apparently of hysterical nature, and pass off. 
Paralysis of oculomotor muscles is in rare cases congen¬ 
ital, occurring in several members of the same family. 
These cases are perhaps of the same nature as those of 
congenital ptosis, absence or imperfect development of 
muscles. Occasionally paralysis of oculomotor nerves 
from birth has been attributed to instrumental labor. 

In respect to the causation of the purely internal par¬ 
alyses we have but little positive knowledge. Mydriasis 
with cycloplegia and no other paralysis would be accounted 
for by disease of the short (third nerve) root of the lenticu¬ 
lar ganglion. Iridoplegia and ophthalmoplegia interna are 
probably the result of chronic, very strictly localized dis¬ 
ease of the centres for the pupil and accommodation 
(Gowers), which have been shown to form separate parts 
of the nucleus of the third nerve. Complete ophthalmo¬ 
plegia interna would also be expected if the lenticular 
ganglion (Hutchinson), or the intraocular ganglionic cells 
of the choroid (Hulke), were disorganized; but such 
changes have not yet been proved post mortem. Paralysis 
from blows on the eye is referred to on p. 182. See also 
Diphtheria, Chapter XXIII. 

Treatment of Ocular Paralyses. In estimating 
the results of treatment it is well to remember that some 
cases recover spontaneously, that in many the defect is a 
paresis rather than paralysis, and that in the latter cases 
the symptoms often vary in severity from day to day, or 
even while under observation at a single visit, according 
to the attention given and effort made by the patient. The 
questions of syphilis and of injury to the head must always 
be carefully inquired into, especially when only one nerve 
is paralyzed. When several nerves are involved, tumor, 


STRABISMUS AND OCULAR PARALYSIS. 39i 


aneurism, or syphilis, either gummatous inflammation at 
the base, or sclerotic nuclear disease, is to be suspected. 
Iodide of potassium and mercury are the only internal 
remedies likely to be beneficial, and unless syphilis be 
quite out of the question they should have a full trial; 
many cases recover quickly under moderate doses of 
iodide. Faradization of the paralyzed muscles is some¬ 
times used. Operation for paralytic squint of old stand¬ 
ing may sometimes be undertaken. 1 

Nystagmus, involuntary oscillating movement of the eyes, 
is generally associated with serious defect of sight dating 
from very early life, such as opacity of the cornea after 
ophthalmia neonatorum, congenital cataract, choroido- 
retinitis, or disease of the optic nerve. It is, however, 
also seen in young babies associated with constant rhyth¬ 
mical rolling or nodding movements of the head (spasmus 
nutans); the nystagmus in these cases usually disappears 
spontaneously. Nystagmus is present in cases of infantile 
amblyopia without apparent cause, and constantly in 
albinoes. Nystagmus is often developed during adult life 
in coal-miners; it has been attributed to the insufficiency 
of light furnished by the safety lamps, and with more proba¬ 
bility to the necessity which the miner is under of constantly 
looking in an unnatural direction, upward or sideways, for 
example; it is often present only when the collier takes up 
his mining posture. It is occasionally seen in other occu¬ 
pations—e. y., among compositors. Nystagmus occurs as 
a symptom in some cases of disseminated sclerosis, and in 
other forms of central nervous disease. 

Usually both eyes oscillate, but when only one eye is 
defective, it alone may oscillate. The movements in nys¬ 
tagmus, whatever may be the cause of the condition, vary 
much in rapidity, amplitude, and direction in different 

1 Rules for operations for paralytic squint have been laid down by Alfred 
Graefe: Arch* f. Oph., xxxiii. 3, 179. 


392 


CLINICAL DIVISION. 


cases, and even in the same case at different times; they 
are generally worse when the patient is nervous, and often 
there is a particular position of the eyes in which the oscil¬ 
lation is least. Nystagmus often becomes much less marked 
as life advances. Treatment is useless. 


CHAPTER XXII. 


OPERATIONS. 

A. Operations on the Eyelids. 

1. Epilation of eyelashes. Position: patient seated ; sur¬ 
geon standing behind. The forceps to be broad-ended, with 
smooth or very finely roughened blades, which meet accu¬ 
rately in their whole width. Stretch the lid tightly by a 
finger placed over each end. Pull out the lashes at first 
quickly in bundles, and finish by carefully picking out the 
separate ones that are left. 

2. Eversion of upper lid. Position as for 1, or the surgeon 
may stand in front. The patient looks down, a probe is 
laid along the lid above the upper edge of the “ cartil¬ 
age the lashes, or the edge of the lid, are then seized 
by a finger and thumb of the other hand, and turned up 
over the probe, which is simultaneously pushed down. 
After a little practice the probe can be dispensed with, and 
the lid everted by the forefinger and thumb of one hand 
alone, one serving to fix and depress the lid, the other to 
turn it upward. 

Fig. 138. 



Meibomian scoop. 


3. Removal of Meibomian cyst. Position as for 1. In¬ 
struments : a small scalpel or Beer’s knife, Fig. 176, and 
a curette, or small scoop, Figs. 138 and 172. 1. Evert the 

lid. 2. Make a free crucial incision into the tumor from 

( 393 ) 









394 


CLINICAL DIVISION 


the conjunctival surface. 3. Remove the growth, either 
by squeezing the lid between finger- and thumb-nail, or 
by means of the scoop. The cavity fills with blood, and 
may thus for a few days be larger than before. These 
tumors have no distinct cyst-wall. 

4. Inspection of cornea in purulent ophthalmia, etc. 
Position : if the patient be a baby or child, the back of 


Fig. 139. 



its head is to be held between the surgeon's knees, its 
body and legs being on the nurse’s lap; if an adult, the 
same as for 1. If the lids cannot be easily sejiarated by a 
finger of each hand, enough to allow a view of the cornea, 
retractors should be used, a convenient pattern is shown in 
Fig. 139, by which one lid, or both, can be raised and held 


Fig. 140. 



J 

Entropion forceps. 


away from the globe. If this instrument be gently used 
we avoid all risk of causing perforation of the cornea should 
a deep ulcer be present, an accident which may happen in 
cases attended by much swelling or spasm of the lids if the 
fingers be used. 























OPERATIONS. 


395 


5. Entropion. Spasmodic entropion of the lower lid, with 
relaxed skin, in old people. Position as for 1. A fold of 
skin close to the edge of the lid and of width proportionate 
to the degree of inversion is removed ; the orbicularis muscle 
is then exposed, and some of its fibres should also be re¬ 
moved ; the wound is then closed with sutures. Another 
good plan is to enter a threaded needle close to the edge of 
the lid, bring it out half an inch vertically below, tie the 
intervening skin and muscle tightly, and allow the thread 
to cut its way out; two or three such stitches will be 
wanted at equal distances apart; the resulting scars being 
vertical are rather conspicuous. 

6. Organic entropion and trichiasis. When the whole 
row of lashes is turned inward, and the inner surface ot 
the lid much shortened by scarring, radical extirpation of 


Fig. 141. 



Snellen’s lid clamp for the R. upper lid. 


all the lashes is the quickest and most certain means of 
giving permanent relief, but it leaves an unsightly bald¬ 
ness, and exposes the cornea to unnatural risk from dust, 
etc. Position : recumbent; the surgeon stands behind the 
patient. Anaesthesia seldom necessary. Instruments: a 
horn or bone lid-spatula, Fig. 142, s, or a lid clamp, Fig. 
141, a Beer’s knife, Fig. 176, and forceps. Make an in¬ 
cision from end to end, beginning just outside the punc- 
tum, between the hair-follicles and Meibomian ducts, as 








396 


CLINICAL DIVISION. 


if to split the lid into two la} r ers. Then make a second 
incision through the skin and tissues, about a twelfth of 
an inch above the border of the lid, parallel with but 
in a plane at right angles to the first. The strip of skin 
and tissues included between these two cuts will now be 
almost free, except at its ends, which are to be united by 
a cross-cut, and the strip dissected off; it should include 
the hair-follicles in their whole depth. Examine the white 
edge of the“ cartilage,” now exposed, for any hair-follicles 
accidentally left behind; they will appear as black dots, 
and are to be carefully removed. 

In the same or slighter cases the inversion of the border 
of the lid may be much lessened by complete division of 
the “ cartilage” from the conjunctival surface along a line 
parallel with and 3 mm. from the free border (Burow’s 
operation). Fig. 143, Bu. The wound gapes and the in¬ 
verted border of the lid falls forward and is kept in its 
natural place by the cornea. The only instruments needed 
are a scalpel and scissors. Position as for 1, or recumbent. 
The lid is kept well everted while the incision is being made. 
A puncture is made with the knife parallel to the edge of 
the lid, close to the inner or outer end, one blade of the 
scissors passed through this puncture and made to run 
along the outer surface of the “ cartilage” between it and 
the orbicularis muscle, and then the “ cartilage” divided 
by closing the blades parallel to the border. The wound 
should be at right angles to the surface. A bluish line 
should be seen through the skin on replacing the lid. 
This operation gives complete relief for the time, but 
may need repetition in a few months. 

Various operations are performed for transplantation of 
the displaced lashes forward and upward, so as to restore 
their natural direction. Arlt’s operation : The free border 
of the lid is split from end to end (leaving the punctum), as 
for extirpation of the lashes, but more deeply, Fig. 142, a. 


OPERA TIONS. 


397 


A second incision (6), extending beyond the ends of the 
first, is now made through the skin parallel to and about 

Fig. 142. 



Arlt’s operation for trichiasis. (After Schweigger.) 


Fig. 143. 



Diagrammatic section of upper lid ; showing Snellen’s operation, and line 
of section in Burow’s operation (Bu). (Altered from Wecker.) 

two lines from the border of the lid, and down to but not 
through the “ cartilagethirdly, a curved incision (c) is 










398 


CLINICAL DIVISION. 


made, joining b at each end and including a semilunar 
flap of skin, of greater or less width according to the effect 
desired ; fourthly, this flap is dissected off without injury 
to the orbicularis, and the wound, hounded by the lines 
b and c, closed by sutures. The anterior layer of the lid 
border, which contains the lashes, is thus tilted forward 
and drawn upward. 

A third operation (Streatfeild’s) consists in the simple 
removal of a wedge-shaped strip of the “ cartilage” (with 
its superjacent skin and muscle) from the whole length of 
the lid at a distance of a line or two from its border. No 
sutures are used. 

Fig. 144. 



Snellen’s operation for trichiasis, s. Edge of retracted skin and muscle. 

(After Wecker.) 


Snellen operates as follows: The incision, b, Fig. 142, is 
carried down to the tarsus, the muscle and skin separated 
from it and pushed upward, and a wedge, shown by the 
groove in Fig. 143, cut from the exposed tarsus, as in 
Streatfeild’s operation. The border of the lid is now 
everted, and kept in its new position by passing two or 
three threads, as shown in Figs. 143 and 144, and tying 
them over beads. The skin wound need not be sutured. 
Various other operations have been introduced from time 
to time for entropion by Spencer Watson and others by 
which a flap of skin is inserted between the lashes and the 










OPERATIONS. 


309 


edge of the lid; the cutaneous hairs on the transplanted 
flap, however, occasionally irritate the cornea. 

All these operations (except l)are apt to need repetition 
sooner or later. 

The above operations are most suitable when the whole 
length of the upper lid is affected; in most hands Arlt’s 
proceeding probably gives better average results than any 
other. In cases of partial trichiasis, where only a few 
lashes are misdirected, electrolysis of the hair-follicles is a 
valuable proceeding ; a needle connected with the negative 
pole of a battery is passed into the follicle by the side of 
the shaft of the hair, the positive pole being applied to the 
skin of the temple. The hair is loosened, comes away, and 
does not grow again; this has to be done to each of the 
displaced lashes. Where only a part of the border is 
affected, transplantation of a strip of mucous membrane 
from the patient’s lip into the gap made by splitting the 
diseased part of the lid, Fig. 145, is the best operation. 
This may be done as follows (van Millingen): 1. Split the 
affected part of the lid as in Arlt’s operation, but turn the 
cut forward into the skin a little at each end, as shown in 
Fig. 145. 2. Separate a strip of mucous membrane from 

the lower lip parallel to its length, leaving its ends at¬ 
tached ; the strip should be longer and wider than the gap 
it is to fill. 3. Take two needles, each with a long thread 
attached, and pass one through each end of the lid in¬ 
cision from the skin surface into the angle of the wound, 
draw the needles through, carry them down to the lip, and 
pass each one through the corresponding end of the bridge 
of mucous membrane from the deep to the free surface. 

4. Cut the attached ends of the bridge, turn the strip over 
on the thumb-nail, and clean its under surface with scis¬ 
sors, taking care not to cut the thread at each end. 

5. Draw the strip up into its new position by pulling on 
the upper ends of the threads, and tie the threads. A 


400 


CLINICAL DIVISION. 


very fine stitch may be inserted at the centre of the flap 
if thought necessary, but this can be dispensed with. The 
split in the lid should be cleaned from clot before the strip 
is brought into position. The strip usually lives and ad¬ 
heres well under an antiseptic dressing; the stitches may 
be left to come out. 

7. Ectropion. Ectropion from thickening of the con¬ 
junctiva, aided by relaxation of the tissues of the lower 
lid, seen chiefly in old people, may be treated by the 
removal of a Y-shaped piece of the whole thickness of the 


Fig. 145. 



Van Millingen’s operation. First stage : the portion of lid containing mis¬ 
directed lashes split parallel to its surfaces, leaving the lashes in the anterior 
layer. The incision at each end is carried a short distance into the skin at a 
right angle with the split. 


lid, the edges being brought together with a harelip pin. 
In Kuhnt’s operation the lid is split by an incision in the 
intermarginal space, and a Y-shaped portion of the inner 
or conjunctival half is removed, the edges being drawn 
together by sutures. In Snellen’s operation the everted 
mucous membrane is drawn back into the sulcus between 
lid and globe by a suture, entered into the conjunctiva at 
two points one-third of an inch apart, passed deeply, brought 
out on the cheek, and tied over a bit of India-rubber tube; 
the thread is tightened from day to day until it has nearly 
cut through. An operation of which the principle is nearly 
the same, but the execution more complicated, is described 




OPERATIONS. 


401 


by Argyll-Robertson. 1 Slighter cases may be satisfactorily 
treated by the excision, or destruction by burning deeply 
with a fine galvanic cautery, of a strip of the palpebral 
conjunctiva parallel to the border of the lid ; the contrac¬ 
tion of the scar draws the margin of the lid into place. 

For ectropion from cicatricial changes in the skin a 
plastic operation is generally needed. At the same time 
the eyelids should be united by fine sutures, after paring 
a narrow strip from the border of each lid just within the 
line of the lashes (blepharoplasty), a proceeding which at 
once assists the restitution of the displaced lid, and gives 
protection to the cornea; the lids may be separated a few 
weeks later. The operation for the cure of the ectropion 
will naturally vary with the seat, extent, and cause of the 
deformity, but we may conveniently distinguish three 


varieties of organic ectropion, according as the condition 
has followed (1) a wound of the eyelid with faulty union ; 
(2) a deejdy adherent scar from abscess, disease of bone, or 
deep ulceration of the lid ; or (3) extensive scarring of the 
face from burns, lupus, etc. When the cause is quite 
localized, and there is not much loss of tissue (groups 1 
and 2), the scar may be included in a Y-shaped incision, 
the flap separated and pushed up till the lid is in position, 
and the lower part of the wound then brought together by 



Fig. 146. 


V Y operation. (From Ritterich.) 


1 Robertson : Edinburgh Clinical and Pathological Journal, December, 1883. 

26 




402 


CLINICAL DIVISION. 


a pin or sutures, so that what was a V now becomes a Y, 
the edges of the flap being attached by sutures to the limbs 
of the Y, Fig. 146. As the lid has generally become too 
long from prolonged eversion, we often have at the same 
time to shorten it by removing a small triangle from its 
outer end, and uniting the edges of the gap. When the 
position of the deformity prevents the above operation, it 
is necessary to introduce new skin into the gap, made by 
dissecting out the cicatricial tissue and putting the everted 
lid into position. This may be done by bringing a flap 
with a broad pedicle, either by sliding or twisting into 
the gap; or by the method, introduced into England by 
Dr. Wolfe, of transplanting from a distant part a single 
graft of skin without a pedicle, large enough to Till the 
gap; or, again, by filling the gap with several small pieces 
of skin. Where there is extensive destruction of skin 
(group 3) these grafting methods seem particularly valu¬ 
able. If a single large graft be used, the important points 
are to make it considerably larger than the deficiency it 
is to supply, to free the under surface of the graft very 
thoroughly of all subcutaneous tissue, and apply warm 
dressings. The single graft operation has now been tried 
many times, and with a good proportion of successes. 

8. Paralytic and congenital ptosis have often been treated 
by the removal of an oval piece of skin from the upper lid, 
parallel to its length, the orbicularis muscle not being 
touched. This simple method, however, has but little 
effect unless the piece removed be so large as to shorten 
the lid materially, and thus endanger the power of com¬ 
plete closure. More complicated operations, intended to 
raise the lid by producing contraction of the subcutaneous 
tissues, or adhesion between these parts and the tendon of 
the occipito-frontalis at the eyebrow without the removal 
of any skin, have been recommended by Pagenstecher, 
Dransart, Meyer, and Panas. I have had, and have seen 


OPERA TIG NS. 


403 


Fig. 147. 



Panas’ operation (after). 













404 


CLINICAL DIVISION. 


in the hands of others, satisfactory results from Panas’ 
operation in several cases. 

9. Canthoplasty, for lengthening the palpebral fissure at 
the outer canthus. The canthus is divided by scissors or 
a knife as far as may seem necessary. The contiguous 
ocular conjunctiva is then slightly dissected up and at¬ 
tached by sutures to the cut edges of the skin, so as to 
prevent reunion, one suture being placed in the angle of 
the wound, one above and one below. Fig. 148. 


Fig. 148. 



Canthoplasty. (From Ritterich.) 


10. Peritomy, for obstinate cases of partial pannus. An- 
festhesia is necessary. Instruments: speculum, fixation for¬ 
ceps, scissors, and Beer’s knife. With the knife a circular 
incision is carried through the conjunctiva, round the cor¬ 
nea, at 5 mm. (£"), or less, from its border. The zone of 
conjunctiva so included, together with the whole of its 
subconjunctival tissue down to the sclerotic, is now care¬ 
fully removed by the scissors. The bare surface thus left 
granulates, and finally contracts to a narrow band of white 
scar-tissue, by which the vessels running to the cornea should 
be obliterated. The subconjunctival fascia is often found 
much thickened in these cases. Care must be taken not to 
make the incision too far from the cornea, lest the inser¬ 
tions of the recti be damaged. The strip removed should 
extend completely round the cornea; removal of only a 
part of the zone is not satisfactory. The symptoms are 






OPERATIONS. 


405 


generally made worse for a time, and the final result is 
not reached for several months. In some cases the opera¬ 
tion has, in my experience, been very successful; while in 
others, without apparent reason, it has quite failed of its 
purpose. A similar effect may be sometimes produced by 
making a small linear burn with the galvano-cautery all 
around the cornea. 

Symblepharon, adhesion of lid to globe after destruction 
of conjunctiva unless very extensive, can be greatly im¬ 
proved by operations. In slight cases we have merely to 
separate the adhesion from the globe and bring together 
the edges of the ocular conjunctiva to cover the surface 
exposed, and thus prevent reunion. But when the surface 
exposed by the dissection is large, flaps of conjunctiva with 
broad pedicles must be brought down to cover the defi¬ 
ciency in the manner first proposed by Teale ;* or mucous 
membrane may be transferred from the lip of the patient, 
or even from the conjunctiva of a rabbit. Snellen has 
lately used a flap of neighboring skin with a pedicle, push¬ 
ing it through a sort of button-hole in the lid, and attaching 
it in the gap made by separating the adhesions. Harlan 
has devised the following operation for the relief of this 
condition. The adhesion is freely dissected until the upward 
movement of the ball is entirely unimpaired, and an external 
incision, represented at a b in the accompanying illustra¬ 
tion, along the margin of the orbit, is carried through the 
whole thickness of the lid, which is thus separated from its 
connections except at the extremity. A thin flap, c d, is 
then formed from the skin below the lid, care being taken 
to leave it attached at its base line by the tissue just 
beneath a b, as well as at the extremities (Fig. 149). On 
this attachment it is turned upward as on a hinge, bring¬ 
ing its raw surface into contact with the inner surface of 


1 Teal: Ophth. Hosp. Reports, iii. p. 253,1861. 


406 


CLINICAL DIVISION 


the lid, and its sound surface presenting toward the ball, 
and held in this position by suturing its edge to the margin 
of the lid. In dissecting up the flap the incisions are car¬ 
ried more deeply into the orbicularis muscle, when the 
base line a b is nearly reached, to enable it to turn more 
readily. The bare space left by the removal of the strip 
of skin is nearly covered without strain by making a hori- 


Fig. 149. 



Harlan’s operation for symblepharon. 


zontal incision, d e, at its outer extremity and forming a 
sliding flap. 

Knapp’s roller operation for trachoma is applicable to all 
cases in which there is a marked development of trachoma 
granules; and it often proves useful when there is great 
thickening of the lid with deposit of similar material deep 
within it, but without any appearance of distinct sago- 
grains upon the surface. The instrument consists of a 
forceps, in each jaw of which is fixed a corrugated roller. 
The upper lid should be everted, one roller thrust far into 
the cul-de-sac, the other placed at the ciliary margin, and 
the two brought together with considerable pressure and 
drawn toward the free folded part of the lid. This is re¬ 
peated until every portion of the lid has been thoroughly 
gone over. The same is done for the lower lid. For the 
lid margins one roller may be placed inside the lid, the 
other on the cutaneous surface. For the retrotarsal folds 






OPERA TIONS. 


407 


as much as possible of the fold is to be grasped between 
the rollers, and the contents pressed out. Especial care 
is required to the conjunctiva near the outer or the inner 
canthus. When bleeding ceases, the eye may be washed 
out with an antiseptic solution. The operation is usually 
followed by great swelling of the lids. But this subsides 
spontaneously in two or three days, or it may be controlled 
by ice applications. As the operation is painful, and should 
be thorough, a general anaesthetic is commonly required. 

B. Operations on the Lachrymal Apparatus. 

1. Lachrymal abscess. (See p. 97). 

2. Slitting up the lower canaliculus. This is best done 

by means of a knife with a blunt or probe point, and a 
blade narrow enough to enter the punctum. The best 
forms of these knives are Weber’s knife, with a probe 
end, Fig. 151; Bowman’s, with nearly parallel borders 
and a rounded end, Fig. 152; and Liebreich’s, Fig. 153. 
Position as for 1. 1. The lower lid is drawn tightly out¬ 

ward and downward by the thumb. 2. The canaliculus 
knife is passed vertically into the punctum, then turned 
horizontally and passed on through the neck of the canal¬ 
iculus till it reaches the bony (inner) wall of the lachrymal 
sac. It is then raised up from heel toward point, and thus 
made to divide the canaliculus, care being taken that the 
neck is freely divided. Liebreich’s knife cuts its own way 
without being raised. The lower canaliculus may also be 
divided with a Beer’s knife, Fig. 176, which is run along 
a fine grooved director, Fig. 150, previously introduced. 
In cases of mucocele it is good practice to divide the wall 
of the sac freely, and some surgeons open the upper as well 
as the lower canaliculus. The canaliculus requires to be 
kept open every three or four days till its cut edges are 
healed, or they will unite again. 

3. Probing the nasal duct. After dividing the canal- 


408 


CLINICAL DIVISION. 


iculus pass a good-sized lachrymal probe horizontally 
along its floor till it strikes the inner (bony) 
fig. iso. wa p t p e sac> Then raise it to the vertical 

position, and push it steadily down the duct, 
downward and a very little outward and back- 


Fig. 151. 



Weber’s canaliculus knife. 


ward, till the floor of the nose is reached. Bow¬ 
man’s earlier probes were in six sizes, of which 

Fig. 152. 



Bowman’s canaliculus knife. 


the largest was one twentieth inch in diameter. 
Bowman afterward adopted much larger probes 


Fig. 153. 



Liebreich’s knife for canaliculus and nasal duct. 


I 


with bulbous ends; and several such patterns 
are now in use. The probe used should be the 
largest that will pass easily. 

4. A stricture of the duct may be incised with 
any of the canaliculus knives, although Weber’s 
and Bowman’s are too slender to be used with 
safety. Liebreich’s is intended to be so used, and a special 
knife for the purpose had previously been introduced by 
Stilling. The knife is used as a probe, being pushed quite 
down the duct, then partly withdrawn, turned in another 


Canaliculus 

director. 
















OPERATIONS. 


409 


direction, and pushed down again. There is generally 
bleeding from the nose. 

In all these procedures we must be certain that the probe 


Fig. 154. Fig.155. 



or knife rests against the bony (nasal) wall of the lachry¬ 
mal sac before it is raised into the vertical direction. If 
























































































410 


CLINICAL DIVISION. 


the probe be stopped at the entrance of the canaliculus into 
the sac, as may easily happen if the canal be not thoroughly 
slit in its whole length, the lid will be pulled upon and 
puckered whenever the instrument is pushed toward the 
nose; but if the probe have reached the sac, backward 
and forward movements will not usually cause puckering 
of the lid. If in the former case the instrument be turned 
up, and an attempt made to pass it down the duct, a false 
passage will probably be made. 

The direction of the two nasal ducts is either parallel, or 
such that if prolonged upward they would converge slightly; 
they very seldom diverge. The probe when in the duct 
should, even if as usual its lower end be curved forward, 
rest against and indent the eyebrow; if it stand forward 
from the brow it is usually in a false passage. 

Lachrymal syringes are of two kinds : 1. Anel’s syringe, 
with a nozzle fine enough to pass into the unopened punc¬ 
tual, Fig. 154. By injecting a little water into the duct 
through the canaliculus we can sometimes clear out slight, 
apparently mucous obstruction, and relieve epiphora with¬ 
out cutting or probing; and by the same method we can 
often decide whether or not there is an obstruction needing 
the severer treatment. 2. Hollow probes attached to 
syringes of various patterns are used for passing down 
the duct and syringing at the same time. Fig. 155 shows 
a simple form sold as Bowman’s. 

Extirpation of the lachrymal gland is indicated in cases 
of neoplasms and extreme hypertrophy, or where there is 
obstinate stillicidium which cannot be controlled in any 
other way. This is accomplished by removing the gland, 
either directly through a skin incision made over the 
gland, or by an incision through the conjunctiva after 
exposure of the cul-de-sac, by division of the external can- 
thus. The latter procedure is the one usually employed, 
as the ptosis which has a tendency to follow the first men- 


OPERA TIONS. 


411 


tioned, due to injury of the levator, is avoided, and the 
resultant scar is much less conspicuous. 

C. Operations for Strabismus. 

Tenotomy. The object is to divide the tendon close to 
its insertion into the sclerotic. Critchett’s subconjunctival 
operation, or the operations of Yon Graefe and Von Arlt 
are the ones commonly employed; the advantages of the 
latter two operations are that the tendon is exposed in its 
whole length, the parts to be divided can be seen, and there 
is no risk of wounding the sclerotic. The internal and 
external recti are the only tendons commonly divided, the 
internal far the more frequently. Anaesthesia is seldom 
necessary except for young children. Instruments: stop 
speculum, Fig. 156, straight scissors with blunted points, 
toothed fixation forceps, strabismus hook. There are sev¬ 
eral forms of hook, differing in the length and sharpness 
of the curve and the shape of the tip. 

Fig. 156. 



Stop-spring speculum. 


Operations. Graefe’s. After the eye has been thor¬ 
oughly cocainized the speculum is introduced, and an in¬ 
cision is made transversely over the insertion of the tendon 
sufficient to expose its whole width; the conjunctiva being 
pushed aside, Tenon's capsule is opened below the tendon; 
the hook is then passed under the tendon, and the latter 



412 


CLINICAL DIVISION. 


divided with the scissors. The conjunctival wound may¬ 
be closed by a single stitch. Von Arlt’s operation differs 

Fig. 157. 



from the one just described in that the squint-hook is dis¬ 
pensed with; after the tendon is exposed it is grasped by 
the fixation forceps and divided. It certainly has the 
merit of being much less painful, and can be used with 
children frequently without a general anaesthetic. Snellen 
makes the conjunctival wound parallel to the muscle to 
avoid gaping. The effect in this and all operations may 


Fig. 158. 



be considerably increased if the various fascial or indirect 
connections of the muscle be divided as well as its tendon. 
This is done (1) by separating the conjunctiva from the 
fascia and its muscle by a burrowing dissection with the 
scissors before the tendon is cut; (2) by freely dividing the 
fascia above and below the tendon, by cutting with the 
scissors upward and downward after having divided the 
tendon itself; (3) by tying the eye out with a silk suture 
passed through the conjunctiva and surface fibres of the 


























OPERATIONS. 


413 


sclerotic, close to the outer border of the cornea, and at¬ 
taching it to the temple for two days by strapping. 

Fig. 159. 



MEYRUWITZ. 


3 > 



Strabismus hook. 



Critchett’s operation. In this operation a fold of conjunc¬ 
tiva is pinched up over the lower border of the tendon close 
to its insertion and divided ; the exposed capsule of Tenon 
is similarly divided. The squint-hook is next passed through 
the opening in the capsule with its concavity downward and 
point backward; the point is then made to sweep around 
between the tendon and globe until its end is seen projecting 
beneath the conjunctiva at the upper border of the tendon. 
The scissors are next passed into the wound with the blades 
slightly open between the hook and the eye and the tendon 
snipped across. When the whole tendon has been divided, * 
the hook comes forward beneath the conjunctiva to the 
edge of the cornea. It is well by introducing the hook to 
make sure that no small strands of the tendon have escaped, 
for the operation does not succeed unless the division is 
complete. 

No after-treatment is needed, but the patient is more 
comfortable if the eye be tied up for a few hours. 

The difficulties for beginners are : (1) to be sure of open¬ 
ing the fascia; (2) to avoid pushing the tendon in front of 
the scissors, especially when only the upper part remains 
undivided. 

Simple division of one internal rectus without separation 
and division of fascia diminishes the squint by about two 






















414 


CLINICAL DIVISION. 


lines (4mm.). The effect, however, is often much less if 
the patient be adult or nearly so. 

LiebreicRs operation is Critchett’s with the addition of 
the separation of conjunctiva from the fascia, and the divi¬ 
sion of the fascia beyond the edges of the tendon described 
at p. 413. These additions to simple tenotomy can be more 
easily and thoroughly applied to Graefe’s operation when 
the incision is over the tendon, and after a considerable 
trial I have ceased to use Liebreich’s method. In any 
case of considerable convergent squint, or squint operated 
on in an adolescent or adult, I prefer Graefe’s method, 
which admits of the maximum effect being easily obtained. 

The immediate effect of the tenotomy of a rectus muscle is 
lessened after a few days by the reunion of the tendon with 
the sclerotic, but after a few weeks or months it is some¬ 
times again increased by the stretching of this new tissue. 

Readjustment or advancement consists in bringing forward 
to a new attachment the tendon of a rectus (generally the 
internal) which has become attached too far back after a 
previous tenotomy, or is acting inefficiently, as in various 
cases of primary divergent squint; advancement of the 
external rectus is also used in simultaneous conjunction 
with tenotomy of the internal in high degrees of con¬ 
vergent squint, especially when the squint is of many 
years’ duration. Indeed, whether performed for divergent 
or convergent strabismus, tenotomy of the opponent muscle 
is generally needed. There are several different operations, 
but in all of them the tendon is held in its new position by 
sutures. The operation is tedious, but may often be done 
under cocaine. The instruments are the same as for ten¬ 
otomy. 

I now generally perform the operation as follows (essen¬ 
tially the method described by Tweedy): 1 1. A stitch of 


1 Tweedy: Lancet, March 22,1884. 


OPERATIONS. 


415 


fine silk is first put through conjunctiva and surface fibres 
of sclerotic close to the inner edge of the cornea and exactly 
on the horziontal line; this is to serve as a guide in case 
the eyeball rotates afterward. 2. The tendon is exposed 
by a vertical wound in the conjunctiva about 5 mm. from 
the corneal border, the fascia opened above and below, and 
a hook passed under the tendon. 3. A stitch is passed 
through the upper part of the muscle alone (not including 
conjunctiva), some way from its attachment, and tied around 
the included part of the muscle, and the needle then passed 
beneath conjunctiva and fascia and brought out above the 
upper edge of the cornea; the lower part of the muscle is 
treated in the same way; the tendon is then divided from 
the sclerotic with scissors, and, if thought necessary, short¬ 
ened by cutting off the portion in front of the sutures. The 
needle carrying the central (guide) thread is now passed 
from behind forward through the muscle between the other 
two sutures and overlying conjunctiva and tied. The upper 
and lower stitches are then tied tightly. The conjunctiva 
is a good deal dragged upon above and below, but soon 
stretches, or the sutures partly cut through. The opponent 
rectus is divided before the sutures are tied. The eyes 
should both usually be kept quietly tied up for several 
days, and the stitches be left in for a week, or until they 
come away, if silk. 

Capsular Advancement .—This operation was introduced 
by de Wecker some years ago, and has been found by the 
Editor to be admirably adapted to the correction of low 
degrees of divergence in the visual axes. The steps in the 
operation, as described by its projector, are as follows: 
The conjunctiva being grasped lightly with forceps 
slightly to the corneal side of the insertion of the muscle 
which is to be advanced, an upward incision is made into 
the conjunctiva parallel with the corneal limbus and 
attaining the height of the upper edge of the cornea, and 


416 


CLINICAL DIVISION. 


a similar one is made below which reaches to the level of 
the lower margin of the cornea. After any bleeding has 
been controlled a small buttonhole is made in the capsule 
of Tenon above and below, and a little externally to the 
insertion of the muscle into the globe. The closed points 
of the scissors are then inserted into one of these holes and 
passed under the muscle in all directions to free the capsule 
from its sublying tissue. These preliminary steps having 
been performed, a delicate curved needle is passed through 
the episcleral tissues at the summit of the cornea, and 
then carried through the buttonhole in the capsule, under 
the capsule for several millimetres, and then finally 
brought out through the conjunctiva and its sublying tis¬ 
sues near the canthus. A similar suture is then passed 
below from the base of the cornea through the lower but¬ 
tonhole, the eye is rotated with forceps in the direction of 
the muscle which is being advanced, and the ends of the 
sutures carefully tied. De Wecker claims for this opera¬ 
tion the power to accomplish all that is gained by a direct 
advancement of the insertion of the muscle itself, without 
the risk of interfering with the axis of the traction of the 
muscle. The operation in the hands of the Editor, how¬ 
ever, has not shown such a wide range of usefulness, for he 
has never been able to obtain but a moderate degree of 
permanent advancing power from it. 


D. Excision of the Eye. 

Instruments as for squint. The operator may stand either 
behind or in front. 1. Divide the ocular conjunctiva all 
around, close to the cornea. 2. Open Tenon’s capsule, and 
divide each rectus tendon and the neighboring fascia on 
the hook ; the two obliques are seldom divided on the hook. 
3. Make the eye start forward by pressing the speculum 
back behind the equator of the globe. 4. Pass the scissors 


OPERATIONS. 


417 


backward along the sclerotic till their open blades can be 
felt to embrace the optic nerve (recognized by its toughness 
and thickness), and divide it by a single cut while steady¬ 
ing the globe with a finger of the other hand. Finish by 
dividing the oblique muscles and remaining soft parts 
close to the globe. Apply pressure for a minute or two, 
aud then tie up slightly for six or eight hours with an 
elastic pad of small sponges overlaid by cotton-wool. There 
is scarcely ever serious bleeding. The artificial eye may be 
fitted in from three to four weeks. 1 

After some weeks or months a button of granulation 
tissue occasionally grows from the scar at the bottom of 
the conjunctival sac, and should be snipped off. 

The operation is more difficult when the eye is ruptured 
or shrunken, or the surrounding parts much inflamed and 
adherent. The order of division of the muscles is imma¬ 
terial. The important points are to leave as much con¬ 
junctiva as possible, so as to form a deep bed for the glass 
eye, and by keeping the scissors close to the globe during 
the whole operation to avoid unnecessary laceration of the 
tissues. 

When, as in some cases of intraocular tumor, it is de¬ 
sired to remove another piece of the optic nerve, the nerve 
should be felt for with the finger, seized and drawn forward 
with the forceps, and cut off further back with the scissors. 

Substitutes for excision of the eyeball. Abscission is the 

removal of a staphylomatous cornea with the front part of the 
sclerotic, leaving the hinder part of the globe with the muscles 
attached to serve as a movable stump for carrying the artificial 
eye. Four or five semicircular needles carrying sutures are made 
to puncture and counter-puncture the sclerotic, just in front of 
the attachments of the recti; the part of the globe in front 

1 The glass eye must be renewed as often as it gets rough, generally at least 
once a year. Some persons have much difficulty in tolerating it, and they 
must he content to wear it for only a part of the day. It is always to be re¬ 
moved at bedtime. 


27 


418 


CLINICAL DI VISION. 


of the needles is cut off, the needles drawn through, and the 
sutures tied. The operation is admissible only when the ciliary 
region is free from disease, and has therefore a very limited 
application ; even in the most favorable cases the stump is not 
entirely free from the risk of setting up sympathetic inflamma¬ 
tion, and I therefore never perform it. It is said that if the 
sutures are passed only through the conjunctiva or the muscles, 
the risk is less than when they are passed through the sclerotic. 

The operation of optico-ciliary neurotomy , in which the optic 
nerve and all the ciliary nerves are divided without removal 
of the globe, with the view of preventing sympathetic disease, 
appears to me to be bad surgery. The sensibility of the 
cornea, abolished by the operation, often returns, proving that 
the ciliary nerves have reunited. The cut ends of the optic 
nerve have also been found reunited, and though union may 
be prevented by exsection of a considerable piece of the optic 
nerve, the same cannot be done with the ciliary nerves. The 
operation, therefore, cannot be relied upon to destroy these, nor, 
it may be added, any of the other possible paths (p. 174) along 
which sympathetic irritation and inflammation may travel; 
indeed, sympathetic inflammation has been observed to follow 
the operation in at least one case. 

Evisceration of the eye, long ago performed in certain cases 
by sundry operators, has been systematically practised and ad¬ 
vocated by Mr. Mules, 1 of Manchester, and Professor Graefe, of 
Halle. The front of the eye is removed at the sclero-corneal 
junction, and the whole contents of the globe emptied out with 
any convenient instrument, very great care being taken to re¬ 
move every trace of choroid and ciliary body. Mr. Mules then, 
after enlarging the scleral opening by a vertical slit, introduces 
into its cavity an hermetically closed, hollow glass ball, and 
stitches the sclerotic carefully over it with fine catgut, the con¬ 
junctiva being separately sewn afterward. The parts should 
be irrigated during the whole operation. There is more reac¬ 
tion than after excision, and if the sclerotic be much inflamed, 
or if suppuration occur, the stitches may give way. The in¬ 
troduction of the glass globe is not an essential part of the 

1 Mules: Trans. Ophth. Soc., vol. v. p 200, 1885. 


OPERATIONS. 


419 


proceeding, its object being merely to improve the stump. 
Graefe advocates evisceration as less likely than excision to 
be followed by meningitis—a terrible accident, which every 
now and then occurs. Mules defends it as likely to be, equally 
with excision, a safeguard against sympathetic disease, while 
allowing a better stump for the artificial eye. 

A number of operators have sought to gain the same 
cosmetic effect as that obtained by the Mules operation, 
without exposing the patient to the danger of sympathetic 
trouble, by removing the eyeball in its entirety, and im¬ 
planting a glass ball within Tenon’s capsule. The best of 
these procedures is that which has been lately introduced 
by Oliver. The steps in this operation are as follows: 1 

“ The conjunctiva around the entire corneal limbus is 
freed from the globe and dissected sufficiently far back so 
as to expose the tendons of the four recti muscles. The 
tendinous extremities of the muscles are made ready for 
separation from the globe. A half-curved needle with its 
point directed toward the corneal border, and holding a 
long piece of catgut thread, is carried directly through the 
belly of the internal or the external rectus muscle, and 
brought out of the tendon of the muscle just behind the 
remaining attachment to the globe. The muscle thus 
secured is cut loose from the globe just as in an ordinary 
tenotomy. The catgut thread is drawn through as far as 
practicable, and a sufficient length of the strand of gut is 
left untouched in order to allow a loop broad enough for 
free manipulation between it and the eyeball. The needle 
is carried over to the opposite side of the cornea, and, with 
its point directed away from the cornea, is made to trans¬ 
fix the tendinous belly of the other lateral muscle, which 
is severed and freed from its connection with the eyeball. 
The vertically placed muscles are dealt with in a similar 
manner. The four recti muscles are thus freed from their 


1 Philadelphia Medical Journal, May 27, 1899. 


420 


CLINICAL DIVISION. 


tendinous attachments to the globe, and each pair of mus¬ 
cles is secured in a loose sling that can be tied the moment 
that this becomes necessary. Working in between the 
broad loops of catgut attached to the ends of the muscles 
that are held apart by an assistant, the eyeball is enucle¬ 
ated with as much of the optic nerve as may be desired, 
without any difficulty. The cavity previously occupied by 
the globe is thoroughly cleansed and a water-tight glass 
ball of about three-fourths the size of the normal globe is 
dropped into place. The ends of the lateral rectus mus¬ 
cles which are held by the lower and the first placed catgut 
thread are neatly trimmed and sutured together. The 
same is done with the two ends of the vertical rectus mus¬ 
cles. The circular opening made by the cut edges of the 
overlying conjunctiva is lengthened into a lozenge by a 
couple of horizontal snips, and is carefully brought into 
linear apposition by a series of silk threads. The opera¬ 
tive field is covered by a gauze protective-bandage upon 
which ice compresses are placed.” 

E. Operations on the Cornea. 

1. Removal of foreign bodies. Instruments: a steel spud, 
Fig. 160, or a broad needle with double cutting edge, Fig. 
161. A 2 per cent, solution of cocaine is to be dropped in 


Fig. 160. Fig. 161. 



Corneal spud. Broad needle. 


two or three times within five minutes. The operator 
stands behind the patient, who is seated in a chair, and 
keeping the lids apart with his index and ring fingers, 
steadies the eyeball by placing his middle finger against 
its outer or inner side. The chip is gently picked or tilted 
off by placing the edge of the spud beneath it, or, if firmly 
embedded, a certain amount of scraping may be necessary. 













OPERA TIONS. 


421 


If the foreign body be barely embedded in the epithelium, a 
touch with a little roll of blotting-paper will often detach it. 
When a fragment of iron has been present for more than a 
couple of days its corneal bed is usually stained by rust, and 
a little plate or ring of brown corneal slough can often be 
picked off after the removal of the chip ; but, as a rule, this 
minute slough may be left to separate spontaneously. 

After-treatment. Tie the eye up, so as to protect the 
corneal surface from friction and irritation. Atropine is to 
be used if there be marked congestion and photophobia. 

When a splinter is deeply and firmly embedded, especi¬ 
ally if it have penetrated the cornea and is projecting into 
the anterior chamber, its removal is often very difficult. 
Unless great care be taken the splinter in such a case may 
be pushed on into the chamber, and the iris or lens be 
wounded. This may sometimes be prevented by passing 
a broad needle through the cornea at another part, and 
laying it against the inner surface of the wound, so as to 
form a guard or foil to the foreign body, the latter being 
removed by spud or forceps from the front. 

A foreign body in the anterior chamber should in recent 
cases always be removed, and the piece of iris on which it 
lies must generally be excised. In cases of old standing 
we may judge by the symptoms whether to operate or not. 

2. Paracentesis of the anterior chamber. Position as for 
1, or recumbent; general anaesthesia not necessary. In¬ 
struments: a paracentesis needle, Fig. 162, with a very 


Fig. 162. 



Paracentesis needle and probe mounted on same handle. 


small, short, triangular blade, bent at an obtuse angle, like 
a minute bent keratome ; or a broad needle, Fig. 161. The 
former is more safe, as the blade is too short to reach the 








422 


CLINICAL DIVISION. 


iris or lens, even if the patient should jerk his head. If 
the contents of the chamber do not follow the needle on 
its withdrawal, a small probe, Fig. 162, is passed into the 
wound. In cases where the operation needs repeating every 
day or two the original wound can generally be reopened 
with the probe. Speculum and fixation forceps should be 
used unless the patient has good self-control. 

3. Corneal section for hypopyon ulcer. Position recum¬ 
bent ; general anaesthesia seldom needed. Instruments: a 
Graefe’s or Beer’s cataract knife, Figs. 170 and 176, spec¬ 
ulum and fixation forceps. The incision is carried through 
the whole thickness of the cornea from one side of the ulcer 
to the other, being both begun and finished in sound tissue. 
Or it may be placed entirely in sound cornea, or at the 
sclero-corneal junction, leaving the ulcer untouched; the 
last position avoids all risk of wounding the lens. 

The knife is entered at an angle with the plane of the 
iris, its edge straight forward; when its point is seen, or 
judged to have perforated the cornea, the handle is de¬ 
pressed until the back of the knife lies parallel with the 
iris, and the blade then pushed straight across the ulcer to 
the point chosen for counter-puncture; often in practice 
it is simply pushed on till it cuts out. The aqueous ought 
not to escape until the point of the knife is engaged in its 
counter-puncture, but an earlier escape cannot always be 
avoided. If it be desired to keep the wound open, its edges 
are to be separated by a probe every second or third day. 
The wound closes quickly at first unless kept open, but 
after having been opened a few times it sometimes remains 
patent for longer. 

4. Cauterization of the cornea is best performed with a 
very fine galvano-caustic terminal. The finest terminal of 
Paquelin’s instrument may be used, but its action cannot 
be so well localized owing to the greater bulk of the heated 
metal. If the eye be much congested, I generally apply 


OPERA TJONS. 


423 


solid cocaine hydrochlorate to the part to be burnt and to 
the part where the fixation forceps will be applied. 

Operations for Conical Cornea. The object is to 
produce a scar at the apex of the cone, which by contract¬ 
ing shall reduce the curvature, and so diminish the high 
degree of irregular myopic astigmatism to which the con¬ 
dition gives rise. 

There are several methods. 1. Graefe’s treatment con¬ 
sisted in first carefully shaving off the apex of the cone 
without entering the anterior chamber, and then producing 
an ulcer by touching the raw surface with solid mitigated 
nitrate of silver (F. 1), and so obtaining a scar. This 
method is more painful and less safe than others, and is now 
seldom used. 2. In another operation the apex of the 
cone is cut off with a cataract knife, the anterior chamber 
being entered, and the wound either left to close or united 
by sutures; there are several different modes of removing 
the little piece. 3. Sir William Bowman removed the 
outer layers of the cone by means of a very delicate cut¬ 
ting trephine, and left the surface to heal and contract. 
4. The galvanic cautery is now being a good deal used 
instead of the knife or trephine; I have found that the 
opacity left by the cautery is apt to engage a larger area 
than that caused by the cutting operations, but more ex¬ 
perience is needed before deciding on the relative merits 
of Nos. 2 and 4. 

After-treatment. Atropine and compressive band¬ 
age until the wound has closed ; antiphlogistic treatment, 
and heat locally, if inflammatory symptoms arise. 

All operations for conical cornea are difficult to perform 
and somewhat uncertain in result, but in many cases vision 
improves, from barely seeing very large letters before oper¬ 
ation to reading small print afterward. The final result is 
never gained for several months. An artificial pupil may 
be necessary if a large corneal opacity finally remain. 


424 


CLINICAL DIVISION. 


F. Operations on the Iris. 
portion of the iris is very often removed by operation 
(iridectomy), with various objects. The principal of these 
are: (1) the direct improvement of sight by altering the 
position and size of the pupil (artificial pupil); (2) to in¬ 
fluence the course of an active disease—glaucoma, iritis, 
ulcer of the cornea with hypopyon ; (3) to remove the risks 
attending “exclusion” and “ occlusion” of the pupil by 
restoring communication between the anterior and poste¬ 
rior chambers; (4) as a stage in the extraction of cataract. 

Iridectomy often causes astigmatism by giving rise to flatten¬ 
ing of that meridian of the cornea which forms a right angle 
with the operation wound, and by bringing the edge of the 
cornea and lens into use permits the spherical aberration, Fig. 
9, which the iris naturally prevents; striae, if present in the 
lens, add to these difficulties, all of which are, cceteris paribus, 
greater if the artificial pupil be large and uncovered by the 
upper lid. Thus it is evident that an artificial pupil should 
seldom be made for the optical improvement of sight unless 
the opacity in or over the natural pupil be such as to interfere 
seriously with visual acuteness. 

Artificial pupil. The object is to remove the portion of 
iris in the position best adapted to sight; thus, in cases of 
leucoma the iridectomy is made opposite the clearest part 


Fig. 1G3. 



Iridectomy downward and inward for artificial pupil. 

of the cornea. When the state of the cornea allows it, the 
new pupil should be made down-inward or straight down¬ 
ward ; the next best place is outward or out-upward; and 
straight upward is, of course, least useful, because the new 
pupil will be covered by the lid. The coloboma should 


OPERATIONS. 


425 


generally be small, and often only the inner (pupillary) 
part of the chosen portion is to be removed, the outer 
(ciliary) part being left, Fig. 163, so as to prevent the 
light passing through the margin of the lens (p. 40). After 
such au operation the pupil will be oval or pear-shaped, and 
widest toward the centre. The incision should lie in the 
corneal tissue if only the pupillary part of the iris is to be 
removed ; but if only a narrow zone of cornea remain clear 
the incision must lie a little outside the sclero-corneal junc¬ 
tion, lest its scar should interfere with the transparency of 
the remaining clear cornea. The loop of iris should be cut 
off with a single snip. 

In iridectomy for glaucoma the coloboma is to be large, 
the iris to be removed quite up to its ciliary attachment, 
and the incision to lie as far back in the sclerotic as pos¬ 
sible ; 1 to 2 mm. from the border of the cornea is not too 
far. The coloboma should be wider toward the wound 
than toward the pupil, so as to form a “ keyhole pupil,” 
Fig. 164. The loop of iris, when drawn out, is usually cut 

Fig. 164. 


Iridectomy for glaucoma. (De Wecker ) 

first in one angle of the wound, then torn from its ciliary 
attachment by carefully drawing it over to the other angle 
of the wound, and its other end cut there. 

The difficulty of making an artificial pupil for optical 
purposes of the best shape— i. e., broad toward the natural 
pupil and narrow toward the circumference, is, owing to 
the small size of the parts, much greater than would be at 
first supposed, and several methods are in use. In Mr. 
Critchett’s iridodesis a loop of iris is drawn out, and 
strangulated by a fine ligature tied around it over the 



426 


CLINIC A L I) 1 1 r IS I ON. 


incision; the little loop soon drops off, and the result is 
a pear-shaped pupil, with its broad end toward the centre. 
Irritation and even destructive iridocyclitis sometimes 
follow, and the operation has therefore been abandoned. 


Fig. 165. 



Another plan is to draw out a small loop of iris with a 
blunt hook (Tyrrell’s hook), and to cut off only the pupil¬ 
lary portion ; this method is uncertain, but, on the whole, 
it gives good results. 








OPERATIONS. 


427 


Iridotomy (iritomy). In this operation an artificial pupil 
is formed by the natural gaping of a simple incision in 
the iris. It is only applicable when the lens is absent. 
Through a small incision in the cornea, between the 
centre and margin, the scissors (shears) shown at Fig. 
146 are passed; the more pointed blade is passed behind 
the iris as far as is deemed necessary, and the iris and 
false membrane divided by a single closure of the blades. 
It is sometimes necessary to make a second cut at an angle 
with the first, so as to include a V-shaped tongue of iris 
which will shrink and allow a larger pupil. 

Iridotomy is most useful when the iris has become tightly 
drawn toward the operation scar by iritis occurring after 
cataract extraction, Fig. 178. The line of the cut in the 
iris should lie, as nearly as may be, across the direction of 
its fibres, and should always be as long as possible. In 
cases of this sort, or when, even without such dragging of 
the iris toward the scar, the pupil is filled by iritic or 
cyclitic membrane after cataract extraction, iridotomy 
yields a better pupil than iridectomy, with less disturb¬ 
ance of, and no dragging upon, the ciliary body. 

The Operation of Iridectomy. Position recumbent; 
the operator usually stands behind. Anaesthesia is often 


Fig. 1G6. 



advisable, but many operators prefer cocaine; I myself 
prefer general anaesthesia whenever the operation is crit¬ 
ical or likely to be difficult. Instruments : stop speculum, 
Fig. 156, fixation forceps, bent keratome, Fig. 166, iris 
forceps, bent at various angles according to the position of 
the iridectomy, Fig. 168, iris scissors, De Wecker’s or those 








428 


CLINICAL DIVISION. 


with elbow bend, Fig. 167, of which some patterns have 
one or both blades probe-pointed, a curette, Fig. 172, or 
small metallic spatula for replacing the cut ends of the iris, 

Fig. 167. FlG - 168 - 




and preventing their incarceration in the angles of the 
wound. The iridotomy scissors, Fig. 165, are very con¬ 
venient, especially for downward and inward operations, 
























OPERATIONS. 


429 


and for the left hand. Most operators prefer Graefe’s 
cataract knife, Fig. 170, to the triangular keratome in 
iridectomy for glaucoma. 

The conjunctiva is held by the fixation forceps near the 
cornea, at a point opposite to the place selected for punc¬ 
ture. 1. The keratome is to be entered slowly, steadily 
pushed on across the anterior chamber till the wound is 
of the desired size, then slowly withdrawn, and, in with¬ 
drawal, its blade carefully turned to one side, so as to 
lengthen the internal wound. Two points need attention : 
as soon as the point of the knife is visible in the anterior 
chamber, it must be tilted slightly forward to avoid wound¬ 
ing the iris and lens; and care must be taken not to tilt it 
sideways, for if this be done the wound, instead of lying 
parallel with the border of the cornea, will lie more or less 
across that line. The incision is made almost as much by 
lifting the eye against the knife with the fixation forceps 
as by pushing the knife against the eye. The forceps are 
now laid down, or if fixation be still necessary, they are 
given to an assistant, who is to gently draw the eye into 
the position required for the next step; in so doing he is 
to draw away from the eye, not to push the ends of the 
forceps against the sclerotic. 2. The iris forceps are in¬ 
troduced, closed, into the wound, and passed very nearly 
to the pupillary border of the iris before being opened, 
and made to grasp it. By seizing the pupillary part of 
the iris its inner circle is certain to be brought ouside the 
wound, when the forceps are now withdrawn; if the iris 
be seized in the middle of its breadth a buttonhole may be 
cut out, and the pupillary part left standing. Often the 
iris is carried into the wound by the gush of aqueous as 
the keratome is withdrawn, and it is then seized without 
passing the forceps so far into the chamber. 3. The loop 
of iris having been cut off, either at a single snip, or by 
cutting first one end and then the other, as in glaucoma 


430 


CLINICAL DIVISION. 


(p. 425), the tip of the curette or spatula is passed into 
each angle of the wound to free the iris should it be 
entangled; it is important to make sure that no iris is left 
incarcerated in the track of the wound. The speculum is 
now removed, and the eye, or both eyes, bandaged over 
a pad of cotton-wool, either with a four-tailed bandage of 
knitted cotton, or two or three turns of a soft cotton or 
flannel roller. 

The anterior chamber is refilled in twenty-four hours, 
except in cases of glaucoma, when the wound frequently 
leaks more or less for several days. It is as well in all 
cases to keep the eye bandaged for a week, the wound 
being but feebly united, and likely to give way from any 
slio-ht blow or other accident. When the incision lies in 
or partly in the sclerotic, some bleeding generally occurs; 
when the eye is much congested this hemorrhage is con¬ 
siderable, aud the blood may run into the anterior chamber 
either during or after the excision of the iris; it can be 
drawn out by depressing the lip of the wound with the 
curette, but if the chamber again fills, no prolonged efforts 
need be made, since the blood is usually absorbed without 
trouble in a few days. In diseased, especially glaucoma¬ 
tous eyes, however, its absorption is often slow. Secondary 
hemorrhage sometimes occurs from a diseased iris several 
days after the operation. 

Sclerotomy is an operation for dividing the sclerotic near 
to the margin of the cornea. It is employed in glaucoma 
instead of iridectomy, or after iridectomy has failed. The 
pupil is to be contracted as much as possible by eserine before 
the operation. It is often performed subconjunctivally, a 
Graefe’s cataract knife, Fig. 170, being entered through 
the sclerotic near the margin of the cornea, 1 passed in front 


1 De Wecker makes it 1 mm. from the clear cornea. In my own operations 
the distance is generally about 2 mm. 


OPERATIONS. 


431 


of the iris, and brought out at a corresponding point on 
the other side, so as to include nearly one third of the cir¬ 
cumference ; the puncture and counter-puncture are then 
enlarged by slow, sawing movements; the central quarter 
of the sclerotic flap and the whole of the conjunctiva (ex¬ 
cept at the punctures) are left undivided. The knife is 
then slowly withdrawn. The whole operation is to be done 
very slowly, that the aqueous may escape gradually ; any 
rush of fluid is likely to carry the iris into the wound and 
cause a permanent prolapse, a result to be carefully avoided. 
If prolapse occur the iris should be excised, and the opera¬ 
tion then becomes a very peripheral iridectomy. A moder¬ 
ate degree of bulging and separation of the lips of the two 
scleral wounds takes place for a week or two, when the scar 
flattens down, and finally a mere bluish line is left. Scle¬ 
rotomy is also performed with a triangular keratome, Fig. 
166, the incision being just as for a very peripheral iridec- 


FlG. 169. 



Diagrammatic section of ciliary region, showing path of wound in iridectomy 
for glaueoma (I) and in sclerotomy (S). Compare Fig. 100, 1 and 2. 

tomy, but no iris being removed or allowed to prolapse. 
Sclerotomy is difficult to perform well, is not free from 
risk, and on the whole has not answered early expecta¬ 
tions; it is, however, valuable as a reserve for certain 
cases. In Fig. 169, I shows the line of incision in iridec¬ 
tomy for glaucoma, and S the line in sclerotomy. 


432 


CLINICAL DIVISION. 


G. Operations for Cataract. 

1. Extraction of cataract lias been systemati¬ 
cally practised for nearly a century and a half. 
The operation has passed through several im¬ 
portant changes, and procedures differing more 
or less from each other are still in use. All the 
operations are difficult to perform well, and 
much practice is needed to ensure the best pros¬ 
pect of success. The sources of possible failure 


Fig. 170. Fig. 171. 



Graefe’s cataract knife. Cataract spoon. 

are many, and as in avoiding one we are apt 
to fall into another, it cannot be expected that 
any one operation will, in all its details, ever be 
universally adopted. At present the majority 
of surgeons adhere more or less closely to the 
operation known as the “ modified linear” 
method of von Graefe, in which iridectomy forms 
a step in the proceeding. Many operators, 
however, dispense with iridectomy on account of 


Fig. 172. 





Cystitome 
(upper end) 
and curette 
(lower end). 







































OPERATIONS. 


433 


the cosmetic and optical advantages of a round pupil. That 
many cataracts can be easily and safely extracted without 
iridectomy admits of no doubt; and it appears equally cer¬ 
tain that some cases, especially where the lens is very hard, 
cannot be dealt with properly in this way. Any operator 
of experience is fully justified in leaving the iris intact 
unless there be difficulty in delivering the lens through 
the pupil, or difficulty in perfectly replacing the iris after¬ 
ward, or the patient be very restless; in either of these 
events iridectomy should be performed at the moment 
when required. Eserine used just before and a few times 
after the operation appears to assist in preventing prolapse 
of the iris afterward. If prolapse occurs, as it may sev¬ 
eral days after operation, it is best to remove it carefully, 
as in a case of accidental wound (p. 190). 

All operations for extraction of hard cataract agree on 
the following points : 1. An incision is made in the cornea, 
at the junction of cornea and sclerotic, or even slightly in 
the sclerotic, large enough to give exit to the crystalline 
lens unbroken and unaltered in shape. The knife now 
almost universally employed is the narrow, thin straight 
knife of von Graefe, Fig. 170. 2. The capsule is freely 

opened with a small sharp-pointed instrument, cystitome 
or pricker, Fig. 172. 3. The lens is removed through the 

rent in the capsule (the latter structure remaining behind), 
either by pressure and manipulation outside the eye, or by 
means of a traction instrument, scoop or spoon, Fig. 171, 
passed into the eye just behind the lens. Few operators, 
however, use the scoop, except for certain emergencies and 
special cases. 4. Iridectomy is very often performed as 
the second stage. This part of the operation was origin¬ 
ally introduced, less with the object of facilitating the exit 
of the lens than with that of preventing prolapse of the iris 
and lessening the after-risks of iritis. But these untoward 
results do not occur so often with cocaine and antiseptics 

28 


434 


CLINICAL I)I VISION. 


as formerly; and, as already stated, many now omit iridec¬ 
tomy. A few of the many surgeons who adhere to iridec¬ 
tomy prefer to perform it some weeks or months before the 
extraction of the lens, preliminary iridectomy; the theory 
being that iritis is less likely to follow if the cut edges of 
the iris are soundly healed before the lens rubs against them 
on its way out. Patients, however, will not or cannot 
always submit to this subdivision of the operation for cata¬ 
ract, and for this and other reasons of expediency prelim¬ 
inary iridectomy cannot be employed so largely as may, 
perhaps, on theoretical grounds be desirable. In my own 
practice I keep it for cases where special risks or difficul¬ 
ties are present, as, e. g., where the patient has only one 
eye. 

The following are the chief varieties of operation for 
cataract at present practised : 

(a) Simple linear extraction, best described here, though 
not applicable to hard cataract. A small incision (4 to 6 
mm.) is made by a keratome, Fig. 166, well within the 
margin of the cornea, with a small iridectomy if necessary. 
After opening the capsule the lens is squeezed out piece¬ 
meal, or coaxed out by depressing the outer lip of the 
wound with the curette, Fig. 172. Only quite soft cata¬ 
racts, or those in which the nucleus, though firm, is very 
small, can be so dealt with. 

The wish to extend the principle of a straight wound to 
full-sized hard cataracts, led by von Graefe, in 1865, to in¬ 
troduce (6) the modified linear or peripheral linear extrac¬ 
tion, in which the incision lies slightly beyond the sclero- 
corneal junction, Fig. 174, 2, and consequently involves the 
conjunctiva, of which a flap is made. The incision is in¬ 
tended to form an arc of the largest possible circle— i. e., 
of the scleral, not of the corneal curve; its plane, there¬ 
fore, must lie as nearly as may be in a radius of the scleral 
curve, and at a considerable angle with that of the iris, 


OPERATIONS. 


435 


Fig. 175, 2. A large iridectomy is performed as the second 
stage. The incision is made with the Graefe knife, Fig. 
170, which is at first directed toward the centre of the 
pupil and then brought up to the seat of counter-puncture. 
The edge is turned somewhat forward during the greater 
part of the proceeding, and the cut completed by sawing 
movements if needful. The disadvantages of the periph¬ 
eral linear extraction are: the frequency of bleeding from 
the conjunctiva into the anterior chamber, the parts being 
thus obscured ; a considerable risk of loss of vitreous, owing 
to the peripheral position of the wound and sometimes a 
difficulty in making the lens present well; a small but 
appreciable risk that the operated eye will set up sympa¬ 
thetic inflammation, the wound lying in the “ dangerous 
region” (p. 173); lastly, there is a tendency to make the 
wound rather too short in order to avoid some of these 
risks, and thus difficulties are introduced in the clean re¬ 
moval of the lens. Its great advantage lies in the rapid 
healing and consequent small attendant risk of suppurative 
inflammation. 

A variety of this operation consists in placing the incision 
rather further down, and at the same time giving it a some¬ 
what sharper curve, so that itr forms an arc of a smaller 
circle than before, but is still not concentric with the cor¬ 
nea, Fig. 174, 3, upper section. The puncture is directed 
somewhat downward (as at the right-hand end of the fig¬ 
ure), and its plane, which at the puncture and counter¬ 
puncture is almost parallel with the iris, alters to nearly a 
right angle at the summit of the flap. The track of the 
wound, if shaded, would appear as in the figure. 

(c) Short flap (De Wecker). The incision, made with 
the same knife, lies exactly at the sclero-corneal junction, 
and is of such an extent that it has a height of about 3 
mm., one-quarter of the diameter of the cornea, Fig. 173. 
A narrow rim of conjunctiva remains attached to the flap. 


436 


CLINICAL DIVISION . 


The iridectomy, if made, is small, as in Fig. 163. For 
very bulky cataracts this incision is not quite large enough. 

(d) The incision lias nearly the same curve and plane as 
in b, but the greater part of it lies considerably within the 
margin of the cornea, corneal section, and iridectomy is 


Fig. 173. 



Short flap. 

usually dispensed with. Liebreich and Bader made the 
section downward, its plane forming an angle of about 
45° with that of the iris, Fig. 174, 3, lower section. In 
Lebrun’s corneal operation an almost identical section is 
made upward; the upper section of 3, Fig. 174, if placed 
further in the cornea, would nearly represent it. The cor¬ 
neal operations, without iridectomy, are easy to perform, 


Fig. 174. 



I 2 3 


Paths of incision for extraction of cataract. 1, old flap; 2, peripheral 
linear; 3 (upper Fig.), a variety of the peripheral linear ; (lower Fig.) corneal 
section. The wound appears as a narrow slit (2) or a broad tract (1), when 
seen from the front, according to the inclination of its plane. The doited 
circle shows the average outline of the lens. Compare Fig. 175. 


compared with those in which the section lies further back ; 
the wound, however, does not, on the whole, heal so quickly, 
and it is more likely to reopen about the fourth or fifth day. 

(e) Old flap extraction (Daviel, Beer, now very little 
used). The incision was slightly within the visible margin 
of the cornea, concentric with it, and equal to at least half 
its circumference, 1, Fig. 174, thus forming a large arc of 


OPERATIONS. 


437 


a small circle, the plane of the incision being parallel with 
that of the iris, 1, Fig. 175 ; no iridectomy was made. The 
incision was made with the triangular knife of Beer, Fig. 
176, in which the blade near its heel is somewhat wider 

Fig. 175. 



The same section seen in profile showing the plane of the incision in 1, 2, 

and the lower section of 3. 

than the height of the flap, and section being completed 
by simply pushing the knife across the anterior chamber 
flat with the iris, its back corresponding to the base of the 
intended flap. The inner length of the wound is less than 
the outer by the thickness of the obliquely cut cornea at 
each end, 1, Fig. 174. 

The flap operation was usually done without either anaes¬ 
thesia, speculum, or fixation forceps. The after-treatment 
was troublesome. But the great height of the flap, in pro- 


Fig. 176. 



portion to its width, renders it very liable to gape, or even 
to fall forward; and this, with the fact that the whole 
wound lies in corneal tissue, considerably increases the risks 
of large and dangerous prolapse of the iris and of rapid 
suppurative inflammation of the cornea. For these reasons 
the old flap extraction has been almost abandoned in favor 






438 


CLINICAL DIVISION. 


of the peripheral linear, corneal section, and short flap oper¬ 
ations, which yield a much larger average of useful eyes. 

Historically, the flap operation was the earliest; then 
came the linear operation ; thirdly, the modified or periph¬ 
eral linear operation, with iridectomy; then the modern 
corneal operations and short flap, the aim of which is to 
gain the substantial advantages both of the old flap and 
the modified linear methods without the great risks of the 
former or the imperfections of the latter; lastly, iridec¬ 
tomy has, as stated above, been again abandoned, more or 
less completely, by many operators. 

Of other operations the most important is Pagenstecher’s, 
in which the lens is removed by a scoop in its unbroken 
capsule. It is most applicable to cataracts which are over¬ 
ripe or are complicated with old iritis, and to Morgagnian 
cataract (p. 202). 

For methods of dealing with unripe senile cataract see 
p. 205. 

The chief complications which may arise daring extraction 
of cataract are: 1. Too short an incision ; this is best reme¬ 
died by enlarging with a small bent “ secondary knife.” 
2. Escape of vitreous before expulsion of the lens; this is 
a signal for the prompt removal of the lens with a scoop, 
Fig. 171, the vitreous being afterward cut off level with 
the wound by scissors. 3. Portions of the lens remaining 
behind after the chief bulk has been expelled ; they should 
be coaxed out by gentle manipulation after removal of the 
speculum. 

After-treatment of Extraction. The patient is best 
in bed for from four to seven days. The dressing consists 
of a jiiece of soft linen overlaid by a pad of cotton-wool or 
alembroth tissue, and kept in place by a four-tailed band¬ 
age of knitted cotton, or a narrow flannel or open tissue 
roller. Both eyes are to be bandaged. It is advantageous 
to apply outside the bandage a light shield to prevent the 


OPERATIONS. 


439 


patient from striking or rubbing the eye during sleep. The 
room is usually kept partly darkened for about a week, all 


Fig. 177. 



dressings and examinations being made by the light of a 
candle. 

Some operators keep their cataract patients from the first in 
daylight, and with no other dressing than some strips of isin¬ 
glass plaster to maintain closure of the lids. Others bandage 
only the operated eye. Old people occasionally get delirious 
if kept in bed and in the dark after extraction of cataract or 
iridectomy, and for such, at any rate, the ordinary rules as to 
bandaging, darkness, and confinement to bed must be relaxed. 
In my experience the subjects of this delirium have usually 
been alcoholics; but I believe that imprudent use of strong 
mydriatics may produce it in some old persons who have not 
been habitual drinkers. 

During the first few hours there will be some soreness 
and smarting, and at the first dressing, from twelve to 
twenty-four hours after operation, a little blood-stained 







440 


CLINICAL DIVISION. 


fluid; but after this there should be no material discom¬ 
fort, and nothing more than a little mucous discharge, 
such as old people often have. The dressings are removed, 
and the lids gently cleansed with warm water once or twice a 
day, their edges being separated by gently drawing down the 
lower lid, so as to allow any retained tears to escape: this 
cleansing is very grateful to the patient. Some surgeons 
open the lids and look at the eye the day after the opera¬ 
tion ; but many prefer to leave them closed for several days 
unless there are signs that the case is doing badly (p. 206). 
It is a good practice to use one drop of atropine daily after 
the third day, to prevent adhesions should iritis set in ; but 
if no iridectomy have been made, I prefer not to use atro¬ 
pine till about the fifth day, because if the wound should 
reopen while the pupil is dilated prolapse of iris is more 
likely to occur than if the pupil be small. When first ex¬ 
amined the eye is always rather congested from having 
been tied up; but there should be no chemosis, the wound 
should be united so as to retain the aqueous, and its edges 
should be clear. The pupil is expected to be black unless 
it is known that portions of lens matter have been left be¬ 
hind. If all be well the bandage may be left off during 
the daytime at the end of a week or ten days, a shade being 
worn ; but it should be reapplied at night for the first two 
or three weeks, to prevent accidents from movements during 
sleep. At the end of a fortnight, if the weather be fine, 
the patient may begin to go out, the eyes being carefully 
protected from light and wind by dark goggles, and he 
may be out of the surgeon’s hands in from three to four 
weeks. 

After-operations. When iritis occurs (p. 207) the 
pupil becomes more or less occluded by false membrane, 
and the subsequent contraction of this membrane may 
draw the iris toward the scar, so that the pupil is at once 
blocked and displaced, Fig. 178. In slight cases, where 


OPERATIONS. 


441 


the pupil is not dragged out of place, sight is greatly im¬ 
proved by simply tearing across the membrane and capsule 
with a fine needle, and treating the case as after discission 
of soft cataract. In doing this the needle should be passed 
deeply enough to tear the posterior capsule also, so that the 
vitreous, by bulging forward, may keep the opening in the 
capsule patent, compare Discission of Soft Cataract, in which 
care is taken not to go so deeply. But in severer cases an 


Fig. 178. 



Diagram of occlusion and displacement of pupil from iritis after upward 

extraction of cataract. 


artificial pupil must be made, either by iridectomy or 
iridotomy (p. 425). 

2. Solution (discission) operations. In these the lens is 
gradually absorbed by the action of the aqueous humor 
admitted through a wound in the capsule (pp. 204 and 
210). 1. The pupil is fully dilated by atropine. 2. The 

lids are held open by the fingers, or a stop speculum and 
fixation forceps used. 3. A fine cataract needle, Fig. 179, 
is directed to a point a little within the border of the cor¬ 
nea, usually the outer border, and when close to its surface 
is plunged quickly and rather obliquely into the anterior 
chamber. Its point is then carried to the centre of the 
pupil, Fig. 180, dipped back through the lens-capsule, and 
a few gentle movements made so as to break up the centre 
of the anterior layers of the lens. 4. The needle is then 
steadily withdrawn. Special care is taken not to wound, 
nor even touch, the iris, either on entering or withdrawing 
the needle, not to stir up the lens too freely, nor to go so 



442 


CL INICA L DI VISION. 


deeply as to perforate the posterior capsule and so engage 
the vitreous. A general anaesthetic is necessary ouly for 
young children or excessively nervous patients; but it 
should always be in readiness and the patient prepared. 

After-treatment. The pupil to be kept widely dilated 
with atropine (F. 33), a drop being applied after the opera- 

Fig. 179. Fig. 180. 




Cataract needle 


Discission of cataract, 


tion, and at least six times a day afterward, or much oftener 
if there be threatening of iritis.. Ice or iced water is usu¬ 
ally applied constantly for twenty-four to forty-eight hours 
after the operation, 1 as for threatened traumatic iritis (p. 
164), and the patient to remain in bed in a darkened room 
for a few days. A little ciliary congestion for two or three 
days need cause no uneasiness ; but the occurrence of pain, 
increase of congestion, and alteration in the color of the iris 
(commencing iritis) are indications for the application of 
leeches near the eye, and the more frequent use of atropine. 

If the cataract is complete, no marked change will be 
seen for some weeks; if partial, e. g., lamellar, in a day 
or two the part of the lens near the needle wound, and in 
a few days the whole lens, will become opaque. In from 
six to eight weeks the lens will have become notably smaller, 
flattened or hollowed on the front surface. If the eye be 


1 1 have to thank my colleague, Mr. Gunn, for this valuable suggestion. 







OPERATIONS. 


443 


perfectly quiet, but not unless, the operation may now be 
repeated in exactly the same way, and with the same after- 
treatment and precautions, but the needle may be used 
more freely. The bulk of the lens will generally disappear 
after the second operation, but the needle may have to be 
used a third or a fourth time for the disintegration of small 
residual pieces, or in order to tear the capsule if it have 
not retracted enough to leave a clear central pupil. A 
small whitish dot remains in the cornea at the seat of each 
needle puncture. 

Extraction by suction. This operation, like simple linear 
extraction, p. 434, is applicable to complete soft cataracts. 
The pupil is to be dilated by atropine. The lens-capsule 
is opened as in discission, but more freely. Then an incision 
is made obliquely through the cornea, between its centre 
and margin, with a keratome, Fig. 166, or broad needle, 
Fig. 161, and the nose of the syringe passed through the 
wound and gently dipped into the lacerated lens-substance. 
By very gentle suction the semifluid lens-matter is then 
drawn gradually into the syringe. The instrument is not 
to be passed behind the iris in search of fragments. Nearly 
the whole of the lens can thus be removed. The after- 
treatment is the same as for needle operations. Two forms 
of syringe are in use : Teale’s, in which the suction is made 
by the mouth applied to a piece of flexible India-rubber 
tubing; Bowman’s, in which the suction is obtained by a 
sliding piston worked by the thumb moving along the 
syringe. It is often better, and in lamellar cataract neces¬ 
sary, to break up the lens freely with a fine needle a few days 
before using the syringe, and thus allow it to be thoroughly 
macerated and softened in the aqueous humor; atropine 
and ice must be used freely in the interval between this 
needle operation and the suction ; and the surgeon must 
be prepared to interfere before the day appointed for the 
suction, should severe pain or increase of tension occur 


444 


CLINICAL DIVISION. 


from the rapid swelling of the lens (p. 219). Suction is 
more difficult to perform, and perhaps less safe, than simple 
linear extraction, but I have myself no objection to make 
against it. 

Anaesthesia in ophthalmic surgery. Before the intro¬ 
duction of cocaine (October, 1884) there was much diver¬ 
sity of practice in respect to anaesthesia, many surgeons 
preferring to perform extraction of cataract, tenotomy for 
squint, and simple iridectomy without anaesthesia, while 
others preferred ether or chloroform for nearly all opera¬ 
tions. Cocaine has immensely facilitated operating with¬ 
out general anaesthesia ; but of course some will continue to 
use ether or chloroform, where others feel able to rely solely 
on the local anaesthetic. In using cocaine for the eye we 
have to remember that it does not affect the sensibility of 
the borders of the lids, nor in any constant manner that of 
the iris, unless used many times for at least half an hour, 
nor that of the muscles and deeper parts, unless injected 
under the conjunctiva. Hence the introduction and pres¬ 
sure of the speculum are always more or less felt, there is 
usually some little pain when the iris is seized and drawn 
out, and decided pain when, in tenotomy, the tendon is 
stretched on the hook, unless subconjunctival injection 
have been resorted to. It must further be remembered 
that the patient is conscious and knows that something 
critical is being done, and that his good behavior depends 
almost as much on absence of fear as on absence of feeling ; 
and, again, that the painlessness of one step of an opera¬ 
tion, e. g., the section in extraction of cataract, contrasts 
strongly with the sensation or pain felt in another stage, 
e. < 7 ., the iridectomy, and that the patient will be likely to 
start or jump, unless warned, at such a stage. My own 
experience leads me to use cocaine in all cataract extrac¬ 
tions and discissions, unless for some peculiar reason ether 
or chloroform be needed, for nearly all tenotomies and 


OPERATIONS. 


445 


operations for corneal ulcer and conical cornea, and for 
some simple iridectomies ; and to avoid it usually in iridec¬ 
tomy for glaucoma and for synechise, whether anterior or 
posterior. I have not myself used it much for lachrymal 
cases; nor have I excised the eyeball under its influence; 
but it may be used for both purposes with fair success. For 
small lid tumors, subcutaneous injection is very successful. 
For granular lids or lupus of conjunctiva, a strong solution, 
10 to 20 per cent., may be painted on before touching with 
actual cautery or caustics; but it is better for such cases, 
and also whenever the eyeball is congested and painful, to 
use the solid cocaine salt, powdered and rubbed over the 
surface with a brush or the finger. For cataract a solution 
of 2 per cent., or a single disk containing -g-J-g- grain, re¬ 
peated three times within five minutes of the operation, is 
generally quite enough. Solutions should be freshly made. 







PART III. 


DISEASES OF THE EYE IN DELATION TO 
GENERAL DISEASES. 


CHAPTER XXIII. 

In stating very shortly the most important facts bearing 
on the connection between diseases of the eye and of other 
parts of the body, it is convenient to make the following 
subdivisions: (A) the eye changes as part of a general 
disease; (B) the ocular disease as symptomatic of some 
local malady at a distance; (C) the eye sharing in a local 
process, affecting the neighboring parts. 

(For the clinical details of the various eye diseases re¬ 
ferred to in this chapter, see Part II.) 

A. General diseases, in which the eye is liable to suffer. 

Syphilis is, directly or indirectly, the cause of a large 
proportion of the more serious diseases of the eye. 

1. Acquired syphilis. Primary stage: Hard chancres 
are occasionally seen on the eyelid, and even far back on 
the conjunctiva (p. 94). 

Secondary stage: Sore-throat, shedding of hair, erup¬ 
tion and condylomata. Iritis is common between two and 
eight or nine months, and does not occur later than about 
eighteen months after the contagion ; in from two-thirds to 
three-fourths of the cases both eyes suffer ; there is a marked 
tendency to exudation of lymph (plastic iritis), shown by 
keratitis punctata, haze of cornea, and less commonly by 
lymph-nodules on the iris. In some cases there are symp- 

(447) 



448 


GENERAL DISEASES OF THE EYE. 


toms of severe cyclitis, leading to detachment of retina and 
secondary cataract, with little iritis; but the cyclitis of 
acquired syphilis does not give rise to ciliary staphyloma. 
(Compare p. 170.) Syphilitic iritis is sometimes protracted, 
and may relapse after complete subsidence. Choroiditis 
and retinitis generally set in rather later, from six months 
to about two years after the chancre; seldom as late as four 
years. 1 The two conditions are most often seen together, 
but either may appear singly; and in each the vitreous 
generally becomes inflamed. These conditions are essen¬ 
tially chronic, the retinitis being often, and the choroiditis 
sometimes, liable to repeated exacerbations or recurrences; 
while in some cases the secondary atrophic changes progress 
slowly for years, almost to blindness, often with pigmen¬ 
tation of the retina. Syphilitic choroiditis and retinitis 
usually affect both eyes, but often in an unequal degree, 
and even when severe the disease is occasionally limited to 
one eye. Keratitis, indistinguishable from that of inherited 
syphilis, is among the rarest events in the acquired dis¬ 
ease ; when it occurs it is usually in the secondary stage 
of the disease. 

Later periods: Ulceration of the skin and conjunctiva 
of the lids, gummatous infiltration of the lids and sclerotic, 
and nodes in the orbit,,whether cellular or periosteal, occur 
but rarely. Oculomotor paralysis is one of the frequent ocular 
results of syphilis. It may depend upon gumma (syphilitic 
neuroma) of the affected nerve or nerves in the orbit or in 
the skull, or upon gummatous inflammation of the dura 
mater at the base of the skull, matting the nerves together, 
or on disease of nerve-centres. The gummatous nerve-lesions 
seldom occur very late in tertiary syphilis. 

The optic disk is often inflamed or atrophied as an indi¬ 
rect result of syphilitic disease of the eye or of the nervous 

1 A few cases are on record in which it appeared not to have begun till 
about ten years after infection. 


SYPHILIS. 


449 


system; but the terms “ syphilitic optic neuritis” and 
“syphilitic optic atrophy” are not often applicable in 
any more direct sense, compare p. 260. The retinitis of 
the secondary stage affects the disk, and, when atrophy of 
the retina and choroid occur, the disk becomes wasted in 
proportion; while in rare cases the retinitis of secondary 
syphilis is replaced by well-marked papillitis. Such cases 
must not be confused with others, still more rare, in which 
double papillitis, passing into atrophy, occurs with all the 
symptoms of severe meningitis in secondary syphilis. Ter¬ 
tiary syphilitic disease, anywhere within the cranium, com¬ 
monly causes optic neuritis, in the same way as do other 
coarse intracranial lesions (p. 254) ; but neuritis may also 
be caused more directly by gummatous inflammation of 
the trunk of the optic nerve, or of the chiasma. Primary 
progressive atrophy of the disks occurs in association with 
locomotor ataxy and ophthalmoplegia externa of syphilitic 
origin; probably in a few instances the optic atrophy 
occurs alone, or for a time precedes the other changes in 
syphilitic, as it is known to do in non-syphilitic ataxy. 

Sight is liable to be rapidly damaged from severe acute 
loss of blood, especially from the stomach; usually both 
eyes suffer, but often unequally. When seen quite early 
papillitis has been found, but the cases are often not seen 
till the appearances of atrophy have come on. 

2. Inherited syphilis. Iritis corresponding to that in the 
acquired disease is seen in a small number of cases, and 
occurs between the ages of about two and fifteen months. 
It often gives rise to much exudation, leading to occlusion 
of the pupil, and is frequently accompanied by deeper 
changes, cyclitis and disease of vitreous. It is very often 
symmetrical, and is much more common in girls than in boys. 
Choroiditis and retinitis , of precisely the same forms as in 
acquired syphilis, occur at the corresponding period of the 
disease— i. e. } between six months and about three years of 

29 


450 


GENERAL DISEASES OF THE EYE. 


age; and they show as much, some observers think more, 
tendency to the degenerative and atrophic results already 
described; in severe cases there are not uncommonly signs 
of cerebral degeneration. In the later stages, keratitis , 
which is the most common eye disease caused by inherited 
syphilis, occurs. It is most common between six and fifteen 
years old, but is sometimes seen as early as two or three 
years, and is occasionally deferred till after thirty. The 
disease is frequently complicated with iritis and cyclitis, 
and, though tending to recovery, shows a considerable lia¬ 
bility to relapse. It almost always attacks both eyes, 
though sometimes at an interval of many months. When 
the patient is unusually young, the disease as a rule runs a 
mild and short course. The oculomotor palsies occur but 
rarely in inherited syphilis, but a few well-authenticated 
cases are on record. 

Smallpox causes inflammation and ulceration of the cor¬ 
nea, leading, in the worst cases, to its total destruction, but 
in a large number to nothing worse than a chronic vascular 
ulcer. The corneal disease comes on some days after the 
eruption, tenth to fourteenth day from its commencement, 
and after the onset of the secondary fever. Iritis, uncom¬ 
plicated and showing nothing characteristic of its cause, 
sometimes occurs some weeks after an attack of smallpox. 
Only in very rare cases do variolous pustules form on the 
eye, and even then they are always on the conjunctiva, 
not on the cornea. 

Scarlet fever, typhus, and some other exanthemata may 
be followed by rapid and complete loss of sight, lasting a 
day or two, showing no ophthalmoscopic changes, and end¬ 
ing in recovery. Such attacks are believed to be uraemic 
or at any rate dependent on some toxic condition of the 
blood. A peculiarity of these cases is the preservation of the 
action of the pupils to light. Very severe purulent or mem¬ 
branous ophthalmia sometimes occurs during scarlet fever. 


DIPHTHERITIC OPHTHALMIA. 


451 


Diphtheria. By far the most common result is paralysis, 
often incomplete, of both the ciliary muscles— cycloplegia; 
the pupils are not affected except in severe cases, when 
they may be rather large and sluggish. 1 The symptoms 
generally come on from four to six weeks after the com¬ 
mencement of the illness, last about a month, and disappear 
completely. Diphtheritic cycloplegia is usually, but not 
invariably, accompanied by paralysis of the soft palate. 
In most of the cases seen by ophthalmic surgeons the 
attack of diphtheria has been mild, sometimes extremely 
so, the case often being described as “ ulcerated throat;” 
but inquiry often yields a history of other and severer 
cases in the family, and of general depression and weak¬ 
ness in the patient out of proportion to his throat symp¬ 
toms. We find that most of the patients who apply with 
diphtheritic cycloplegia are hypermetropic, doubtless be¬ 
cause those with normal, and a fortiori, with myopic, re¬ 
fraction are much less troubled by paresis of accommoda¬ 
tion, and often do not find it necessary to seek advice. 
Concomitant convergent squint is sometimes developed in 
hypermetropic children during the diphtheritic paresis, 
owing to the increased efforts at accommodation (p. 365). 
Paralysis of the external muscles is occasionally seen; I 
have never myself seen any except the external rectus 
affected, and recovery has been rapid. 

Diphtheritic and membranous ophthalmia are occasion¬ 
ally caused by direct inoculation of the conjunctiva of the 
attendant by diphtheritic material from the patient’s throat; 
or in the patient himself by extension up the nasal duct to 
the conjunctiva. But in many cases of ‘‘ diphtheritic ” 
and “membranous” ophthalmia the disease seems to be 
local, the inflammation taking on this special form with- 


1 Further observations are wanted. 


452 


GENERAL DISEASES OF THE EYE. 


out ascertainable relation to any infectious disease. No 
doubt there is often something peculiar in the patient’s 
health, or in the state of his eye-tissues which gives a pro¬ 
clivity to this kind of inflammation. Thus diphtheritic 
ophthalmia of all degrees is more common in young chil¬ 
dren than in adults; the worst cases generally occur after 
measles, or during or after scarlet fever, broncho-pneumo¬ 
nia, or severe infantile diarrhoea; old granular disease of 
the conjunctiva also confers a liability to a diphtheritic 
type of inflammation, and the same tendency is sometimes 
seen in ophthalmia neonatorum and in gonorrhoeal oph¬ 
thalmia. 

Measles is a prolific source of ophthalmia tarsi in all its 
forms, and of corneal ulcers, particularly of the phlycten¬ 
ular forms. It also gives rise to a troublesome muco-puru- 
lent ophthalmia, and under bad hygienic conditions this 
may be aggravated by cultivation and transmission into 
destructive disease of purulent, membranous, or diphthe¬ 
ritic type. Double optic neuritis has been seen in several 
patients after measles. 

Mumps. Enlargement of the lachrymal gland sometimes 
accompanies or follows that of the parotid. Cases have 
been reported by Hirschberg and others in which the 
lachrymal gland, but not the parotid, was enlarged. Dr. 
Swan M. Burnett 1 called attention to haze of disk with 
venous engorgement of retina and failure of sight during 
mumps. CEdema of lids and conjunctiva, and in one case 
paresis of third nerve, pointed to effusion into the orbit. 
The symptoms as a rule quickly subsided. 

Chicken-pox is sometimes followed by a transient corneal 
attack of mild conjunctivitis. 

Whooping-cough often, like measles, leaves a proneness to 


1 Burnett: American Journal of the Medical Sciences, January, 1886, p. 86, 


EPIDEMIC CEREBROSPINAL MENINGITIS. 453 


corneal ulcers. In a few rare cases the condition known 
as ischcemia retince, sudden, temporary, arterial bloodless¬ 
ness, lias occurred. Conjunctival orbital or cerebral hem¬ 
orrhages may occur during the violent attacks of coughing ; 
the latter may occasion muscular paralyses. 

Influenza. In the epidemics of the last few years many 
ocular complications have been reported, optic neuritis, 
iritis, glaucoma, and muscular defects of various kinds; 
but considering the almost universal prevalence of the 
scourge, such complications must be considered un¬ 
common. 

Malarial fevers, especially the severe forms met with in 
hot countries, are sometimes the cause of retinal and other 
intraocular hemorrhages, and even of considerable neuro¬ 
retinitis ; when there is much pigment in the blood the 
swollen disk may have a peculiar gray color. When renal 
albuminuria is caused by malarial disease, albuminuric reti¬ 
nitis may occur. Simple optic neuritis with failure of sight, 
followed by recovery, seems to occur sometimes, and ambly¬ 
opia of more than one form is said to be produced by mala¬ 
rial poisoning; some cases have recovered under quinine. 
Loss of sight from malarial fever must not be confused 
with blindness due to the quinine administered for its cure 
(p. 457). 

Relapsing fever is sometimes followed, during conva¬ 
lescence, by inflammatory symptoms with opacities in the 
vitreous (cyclitis), with or without iritis; recovery takes 
place. These cases are more common in some epidemics than 
in others. In a large outbreak Lubinski saw no eye cases 
in patients under twenty years of age, and none in 
females. 

Epidemic cerebro-spinal meningitis also, in a few cases, 
gives rise to acute choroiditis, with pain, chemosis, and 
great tendency to rapid exudation of lymph into the vit- 


454 


GENERAL DISEASES OF THE EYE. 


reous and anterior chambers, and often leading to disor¬ 
ganization of the eye and blindness. 1 It is believed that the 
inflammation may extend to the eye along the optic nerve, 
or may occur independently in the brain and the eye. 
Deafness from disease of the internal ear is even more com¬ 
mon than the eye disease. 

Purpura has been observed in a few cases to be accom¬ 
panied by retinal or sub retinal hemorrhages; they are 
sometimes perivascular and linear, and in other cases form 
large blotches. 

In pyaemia one or both eyes may be lost by septic emboli 
lodging in the vessels of the choroid or retina, and setting 
up suppurative panophthalmitis. The symptoms are swell¬ 
ing of the lids, loss of sight, congestion, especially of the 
perforating ciliary vessels, Fig. 24, chemosis, discoloration, 
and dulness of aqueous and iris. There may or may not 
be some protrusion and loss of mobility, and conjunctival 
discharge. Pain, sometimes very severe, may be almost 
absent; probably its presence indicates rise of tension. 
A yellow reflex is often seen from the vitreous. The eye¬ 
ball generally suppurates if the patient live long enough. 
Sometimes both eyes are affected, together or with an in¬ 
terval. In cases of septicoemia abundant retinal hemor¬ 
rhages of large size may occur in both eyes; they come on 
a few days before death, and are thus of grave significance. 
As they are not present in typhoid and other fevers of cor¬ 
responding severity, their presence is sometimes an aid in 
differential diagnosis. 2 

Lead-poisoning is an occasional cause of optic neuro-reti¬ 
nitis leading to atrophy, of atrophy ensuing upon chronic 

1 Possibly a few of the cases in which similar eye conditions are seen 
without apparent cause may be the accompaniments of slight and unrecog¬ 
nized meningitis. (See Pseudo-glioma, p. 226.) 

2 Gowers: Medical Ophthalmoscopy, second edition, p. 255. 


TOBACCO. 


455 


amblyopia, and of rapid, usually transient amblyopia. The 
two former are the most common; the atrophy, whether 
primary or consecutive to papillitis, is generally accom¬ 
panied by very marked shrinking of retinal arteries, and 
great defect of sight or complete blindness; it is generally 
symmetrical, but one eye may precede the other. Other 
symptoms of lead-poisoning, usually chronic, but occasion¬ 
ally acute, are nearly always present. Care must be taken 
not to confuse albuminuric retinitis from kidney disease 
induced by lead with the changes here alluded to, which 
are due in some more direct manner to the influence of the 
metal. 

The deposition of lead upon corneal ulcers has been re¬ 
ferred to at p. 152. 

Alcohol. Some observers still hold that alcohol, especi¬ 
ally in the form of distilled spirits, may cause a particular 
form of symmetrical amblyopia, the so-called amblyopia 
potatorum. Optic neuritis and paralyses of various single 
oculomotor nerves are described by Thomsen as occurring 
in cases of alcoholic paralysis. The difficulty of arriving 
at the truth depends chiefly upon the fact that most drinkers 
are also smokers, and that tobacco, whether smoked or 
chewed, is allowed by all authorities to be one of the 
causes, or, as most now hold, the sole cause, of a similar 
disease. The question whether alcohol directly causes disease 
of the optic nerves will not be settled until observers are 
much more careful than they have hitherto been to record 
as typical cases of alcoholic amblyopia only those in which 
the patient does not use even the smallest quantity of 
tobacco in any shape. 

Tobacco. Whatever may be the truth, and it is con¬ 
fessedly difficult to arrive at, as to the direct influence of 
alcohol, and of the various substance often combined with 
it, there is no doubt whatever that tobacco, whether smoked 


456 


GENERAL DISEASES OF THE EYE. 


or chewed, does act directly on the optic nerves, and in 
such a manner as to give rise to definite, and usually very 
characteristic symptoms. The amblyopia seldom comes on 
until tobacco has been used for many years. The quantity 
needed to cause symptoms is, cceteris paribus, a matter of 
idiosyncrasy, and very small doses may produce the dis¬ 
ease in men who, in other respects also, are unable to 
tolerate large quantities of the drug. Predisposing causes 
exert a very important influence; among these are to be 
specially noted increasing age; nervous exhaustion from 
overwork, anxiety, or loss of sleep; chronic dyspepsia, 
whether from drinking or other causes ; and probably sex¬ 
ual excesses and exposure to tropical heat or light. A 
large proportion of the patients drink to excess, and thus 
make themselves more susceptible to tobacco by injuring 
both the nervous system and the stomach. But some re¬ 
markable cases are seen in men who have for long been total 
abstainers, in others who have lately become abstainers 
without lessening their tobacco, and in yet others who are 
strictly moderate in alcohol, are in robust health, and in 
whom increasing age is the only recognizable predisposing 
cause. The strong tobaccos produce the disease far more 
readily than the weaker sorts, and chewing is more dan¬ 
gerous than smoking. Probably alcohol in very moderate 
doses counteracts rather than increases the injurious effect 
of tobacco upon the nervous system and optic nerves 
(Hutchinson). 

The vapor of bisulphide of carbon, if inhaled in a con¬ 
centrated form and for long periods, produces at first ex¬ 
citement, then general and severe loss of nerve power, with 
extreme mental and muscular debility and impotence. In 
some of the cases the sight fails chiefly in the centre of the 
field, central scotoma, with haze and pallor of the disks, 
chronic neuritis. The cases are met with either in India- 


KIDNEY DISEASE 


457 


rubber works or oil-mills, in both of which the bisulphide 
is largely used. 1 

Quinine, taken in very large doses at short intervals, has 
in a few cases caused serious visual symptoms. Sight in 
both eyes may be totally lost for a time, but recovery more 
or less perfect takes place eventually, sometimes in a few 
days, sometimes not for months. There is a great con¬ 
traction of the visual field even after perfect recovery of 
central vision; the disks are pale and the retinal arteries 
extremely diminished. The symptoms are therefore those 
of almost arrested supply of arterial blood to the retina. 

Kidney disease. The common and well-known retino- 
neuritis associated with renal albuminuria, and of which 
several clinical types are found, has been already described. 
It need only be noted that the disease is most common with 
chronic granular kidneys and in the kidney disease of 
pregnancy, but that it is also seen in the chronic forms 
following acute nephritis and in lardaceous disease, and 
that children suffering from chronic renal disease seem as 
liable to it as adults. Retinitis with renal albuminuria is 
usually a sign that the kidney disease is far advanced, and 
the prospect of life very bad. According to Miley, hospital 
patients seldom live more than six months after the onset 
of the retinitis (Trans. Ophth. Soc., viii. 132). C. S. Bull 
finds that the average duration of life is somewhat longer, 
according to returns from patients of all classes. There is 
no doubt that the prospect of life for patients who are able 
to live carefully is considerably better than for others. It 
seems likely that there is also a group of cases in which the 
retinal change precedes the signs of kidney disease, these 
signs appearing later ; thickening of the coats of the smaller 
retinal arteries, giving them when seen by the ophthalmo- 

i For full particulars, see Trans. Ophth. Soc., vol. v. 1885, pp. 149-175. 
Another case is reported by Gunn : Ibid., vi. 1886, 372. 


458 


GENERAL DISEASES OF THE EYE. 


scope an appearance of bright copper wire, is not infre¬ 
quently seen associated with renal disease of the chronic 
granular form, as has been pointed out by Gunn ; T exam¬ 
ination of the urine often does not reveal the presence of 
renal disease, and it is probable that a sclerosis of the 
small arteries of the body generally may be fairly well 
advanced without the appearance of any signs of affection 
of the kidney. Detachment of the retina is an occasional 
result in extreme cases. The prognosis as regards vision 
is best in the cases depending on albuminuria of preg¬ 
nancy. The retinal oedema and exudation are probably 
caused by the blood-state; but the disease of the small 
bloodvessels and the cardiac hypertrophy, no doubt add 
to and complicate the changes. Indeed, the different types 
of retinal disease which are met probably depend in great 
measure on the varying parts played by the three factors 
alluded to. The failure of sight caused by albuminuric 
retinitis has often led to the correct diagnosis of cases 
which had been treated for dyspepsia, headache, 

“ biliousness.” 

Diabetes sometimes causes cataract. In young or middle- 
aged patients the cataract usually forms quickly, and is of 
course soft. As it is always symmetrical, the rapid forma¬ 
tion of double, complete cataract, at a comparatively early 
age, should always lead to the suspicion of diabetes. In 
old persons the progress of diabetic cataract is much slower, 
and often shows no peculiarities. The relation of the len¬ 
ticular opacity to the diabetes has not been satisfactorily 
explained; the presence of sugar in the lens, the action 
of sugar or its derivatives dissolved in the aqueous and 
vitreous, the abstraction of water from the lens owing to 
the increased density of the blood, and, lastly, degenera- 


1 Gunn : Trans. Ophth. Soc., vol. .xii. p. 124. 


PROGRESSIVE PERNICIOUS AN JEM I A. 459 


tion of the lens from the general cachexia attending the 
disease, have all been offered in explanation. It is impor¬ 
tant to know that diabetic cataract sometimes disappears 
entirely if the health improves, the lens completely clear¬ 
ing up. 1 In a few cases retinitis occurs; sometimes with 
great oedema and copious, probably capillary, hemorrhages 
into the retina and vitreous, in other cases with numerous 
white patches, but no oedema. Plastic iritis sometimes 
occurs in diabetes, both with and without previous opera¬ 
tion ; Schirmer draws attention to the importance of ex¬ 
amining the urine for sugar in cases of intractable iritis. 
Central amblyopia from disease of the optic nerves has 
also been observed, even it is said in patients who were 
not smokers, 2 and according to Hirschberg affords a grave 
prognosis. 

Leucocythsemia is often accompanied by retinal hemor¬ 
rhages, less commonly by whitish spots bordered by blood, 
and consisting of white corpuscles ; these spots may be thick 
mugh to project forward. Occasionally there is general 
haziness of the retina. In severe cases the whole fundus is 
remarkably pale, whether there be other changes or not. 3 
The changes are usually symmetrical. 

Progressive pernicious anaemia is marked by a strong 
tendency to retinal hemorrhages ; these are usually grouped 
chiefly near the disk, and are striated (Gowers). White 
patches are also common, and occasionally well-marked 


1 See cases recorded in Trans. Ophth. Soc., vol. v., 1885, p. 107. 

2 See Leber, in the Graefe-Saemisch Handbuch, and a paper by Dr. 
Edmunds and the author, Trans. Ophth. Soc., vol. iii, 1883. A doubtful case 
in a woman is recorded in the same paper ; and another, also not completely 
satisfactory, by Samuel, in Hirschberg’s Centralblatt, 1882, p. 202. Paper by 
Moore : New York Medical Journal, 1888. 

3 For a full account of the changes see Gowers : Medical Ophthalmoscopy. 
Dr. Sharkey has shown me a case with diffuse retinitis, very numerous puncti- 
form hemorrhages, chiefly peripheral, and dilatation with extreme tortuosity 
of the veins. 


460 


GENERAL DISEASES OF THE EYE. 


neuritis occurs. The author has seen hemorrhages of dif¬ 
ferent dates, and in one case, shown him by Dr. Sharkey, 
there had evidently been a large extravasation from the 
choroid at an earlier period. The disk and fundus partic¬ 
ipate in the general pallor. In simple anosmia optic neu¬ 
ritis or retinitis with hemorrhages is met with: the degree 
of swelling of the nerve is sometimes very great; it may 
result in atrophy with permanent impairment of vision. 
The retinitis sometimes has the appearance of typical renal 
retinitis ; it may be one-sided. 

Hemophilia. As yet, no cases have been recorded in 
which there were hemorrhages into the interior of the eye 
as a result of this disease. Disturbances of vision, how¬ 
ever, have been reported after profuse hemorrhages else¬ 
where, which were probably due to optic atrophy. Priestley- 
Smith saw an interesting case of profuse hemorrhage into 
the orbit following an injury of that cavity in one of these 
subjects. 

Scurvy. In this disease the eyes are so deeply sunken 
and are surrounded by such dark rings that they give an 
appearance almost characteristic of this disease. As in 
purpura, hemorrhages are not infrequent into the retina, 
and these become yellower as the disease progresses. As 
a result of the impoverished supply of nutriment to the 
retina hemeralopia and nyctalopia are occasional symp¬ 
toms. 

In the rare but interesting manifestations of the disease 
in infancy, oedema of the lids has been considered charac¬ 
teristic of the disease by some clinicians. Hemorrhages 
into the lids and orbit are also quite common, and are at 
times very striking. Holmes Spicer has reported three 
cases in which, as a result of profuse bleeding into the 
orbits, there were great swelling of the lids and protrusion 
of the globes. 


HEART DISEASE. 


461 


Secondary Anaemia. Simple loss or diminution in the 
quality of the blood is very rarely followed by ocular 
changes, the additional predisposing factor of impoverished 
blood being apparently necessary to occasion lesions within 
the eye. 

Heart disease is variously related to changes in the eyes 
and alterations of sight. Aortic incompetence often pro¬ 
duces visible pulsation of the retinal arteries. This pulsa¬ 
tion often differs from that seen in glaucoma in extending 
far beyond the disk, and in not being so marked as to cause 
complete emptying of the larger vessels during the diastole. 
In glaucoma the pulsation is confined to the disk. The 
difference is explained by the different mode of production 
in the two cases: in the one, incomplete closure of the 
aortic orifice lowers the pressure in the whole blood-column 
during the diastole, and allows a reflux of blood from the 
eye; in the other heightened intraocular tension, telling 
chiefly on the comparatively yielding tissues of the optic 
disk, increases the resistance to the entrance of arterial 
blood. Valvular disease of the heart is generally present 
in the cases of sudden lasting blindness of one eye, clinic¬ 
ally diagnosed as embolism of the arteria centralis retinae; 
but in some of these thrombosis of the artery or of its 
companion vein, or blocking of the internal carotid 1 and 
ophthalmic arteries, has been found post mortem. Brief 
temporary failure, or even loss of sight may occur in the 
subjects of valvular heart disease, and in some persons who 
are liable to recurring headache. See Megrim. Repeated 
attacks of this kind sometimes lead to permanent blindness 
of one eye, and atrophy of the disk comes on; possibly re¬ 
peated temporary failures of retinal circulation at length 
give rise to thrombosis. In another group of cases sight 


i Gowers : Medical Ophthalmoscopy, p. 26. 


i 


462 


GENERAL DISEASES OF THE EYE. 


fails during successive pregnancies or lactations, recovering 
between times; some of these may be mere accommodative 
asthenopia; others may be due to renal retinitis. Others 
again are due to uraemic poisoning without ophthalmoscopic 
signs; in the last-named the failure affects both eyes, and 
usually develops suddenly. The seat of the affection is 
probably the cerebral cortex. It is probable that high 
arterial tension predisposes to intraocular hemorrhage in 
cases where the small vessels are unsound, and that the 
frequent association of retinal hemorrhage with cardiac 
disease is thus explained. 

Tuberculosis is sometimes accompanied by the formation 
of tubercle in the choroid. These may occur in acute 
miliary tuberculosis, whether the meninges be involved or 
not; but owing to the difficulty of thorough ophthalmo¬ 
scopic examination in such patients, and the frequently 
very small size of the choroidal growths, they are much 
more often seen after than before death. Chronic tuber¬ 
cular tumors of the brain may be accompanied by tubercles 
of slow growth and larger size in the choroid, and occasion¬ 
ally these attain such dimensions, and cause such active 
symptoms, as to simulate malignant tumors 1 (p. 320). It 
is also probable that certain cases of localized choroidal 
exudation, not accompanied by serious general symptoms 
or by inflammatory symptoms in the eye, may be of tuber¬ 
cular nature (p. 226, 4). 

Barlow 2 has seen tubercles in the choroid post mortem in 
sixteen cases; in thirteen with and three without tubercular 
meningitis. Sometimes they took the form of extremely 
minute dots, “tubercular dust.” In forty-four children 

1 For interesting cases of and remarks on choroidal tuberculosis in its 
various forms and relations, see communications by Mackenzie, Barlow, 
Coupland, and others in Trans. Opth. Soc., vol. iii. October, 1882, p. 119, 

et. seq. 

2 Barlow : Ibid., p. 132. 


G ONORRH (EAR RHE UMA TISM. 


463 


who died of tubercular disease, forty-two showing miliary 

tubercles in the meninges, Dr. Money 1 found tubercles in 

the choroid of one or both eves in fourteen. 

«/ 

Rheumatism. In acute rheumatism Dr. Barlow informs 
me that he has more than once seen well-marked conges¬ 
tion of the eyes and photophobia; but neither iritis nor 
other inflammatory changes occur. The subjects of chronic 
rheumatism are, however, liable to relapsing inflammation 
of the eye, usually taking the form of iritis, but sometimes 
falling entirely on the scleral or episcleral tissues; while in 
others less common the changes are apparently confined 
to the conjunctiva—rheumatic conjunctivitis. But, how¬ 
ever superficial the inflammation or congestion may be, 
there is no muco-purulent discharge. Some of these 
patients give a history of acute articular rheumatism as 
the starting-point of their chronic troubles, others of a 
prolonged subacute attack, lasting for many months, while 
in others again the articular symptoms have never been 
severe. In yet another series a liability to facial or mus¬ 
cular rheumatism, or to recurrent neuralgia from exposure 
to cold or damp, is the only “ rheumatic ” symptom of 
which a history is given ; in some of these the neuralgia is 
probably gouty, but we have no exact knowledge of the 
nature of this chronic rheumatism of which complaint is 
so commonly made. It is to be remembered that the eye 
is now and then the first part to be attacked by an inflam¬ 
mation, which later events show to be clearly related to 
rheumatism or to gout. 

Gonorrhoeal rheumatism is not infrequently the starting- 
point of relapsing iritis and the other conditions named 
above, as well as of chronic relapsing rheumatism. Rheu¬ 
matic iritis occurring for the first time with gonorrhoeal 
rheumatism is, in my experience, more often symmetrical 


1 Money: Lancet, ii. 1883, 813. 


464 


GENERAL DISEASES OF THE EYE. 


than other forms of arthritic iritis, or than the later attacks 
of iritis in the same patient—a fact which at times makes the 
distinction between rheumatic and syphilitic iritis difficult. 

This statement is based on records of 104 cases of iritis with 
well-marked rheumatic symptoms, and six with gonorrhoea but 
no rheumatism, in all of which syphilis was, so far as possible, 
excluded, (a) In thirty-four of this series the first attack of 
iritis came on during, or very soon after, gonorrhoeal rheuma¬ 
tism ; and in exactly one-half of these the iritis was double. 
In six others, making forty in all, there were iritis and gonor¬ 
rhoea, but no rheumatism, “ gonorrhoeal iritis,” and here the 
proportions were the same. ( b ) In the remaining seventy cases 
the first iritis had no relation to gonorrhoea; and in the sub¬ 
series the attack was single in fifty-six and double in, at the 
most, thirteen, two or three being doubtful, or about one-fifth. 
No corresponding difference obtained in regard to relapses, the 
vast majority of the recurrent attacks in both subgroups (a and 
b) affecting only one eye at a time. 

Gonorrhoeal iritis. Some cases of gonorrhoeal iritis have 
been described in which there is iritis due to gonorrhoea 
without arthritis being actually present. Probably in these 
cases the iritis is the first indication of gonorrhoeal rheu¬ 
matism. A variety of quiet conjunctivitis, not due to infec¬ 
tion has also been described without pain, and hardly any 
discharge. 

Rheumatic inflammation of the conjunctival or scleral 
type occurring in gonorrhoea must be carefully distin¬ 
guished from purulent ophthalmia due to infection with 
gonorrhoeal pus. 

In some cases of acute inflammation of joints in infants 
suffering from purulent ophthalmia, the arthritis is be¬ 
lieved to be gonorrhoeal, but derived from the conjunctiva 
instead of the urethra. 1 In a case of this sort fluid 

1 Clement Lucas: Brit. Med. Journ., ii. 1885, pp. 57 and 699; Fenwick: 
Ibid., p. 830 ; Saswornitzky : abstracted in Knapp’s Archives, xv. 1886, p. 232; 
Deutschmann : Arch. f. Ophth., xxxvi. 1, p. 109. 


GOUT. 


465 


obtained from the knee-joint was found by Deutschmann 
to contain gonococci. 

It is believed that rheumatism is the cause of some cases 
of non-suppurating orbital cellulitis, and of relapsing epi¬ 
scleritis. Rheumatism is also believed to cause some other 
of the ocular paralyses. 

G-out. Gouty persons are not very infrequently the sub¬ 
jects of recurrent iritis indistinguishable from that which 
occurs in rheumatism. The pathology of rheumatism is 
so little understood that it it is not possible to distinguish 
it in some of its forms from gout; but that the subjects of 
true “ chalk gout ” are liable to relapsing iritis is undoubted. 
There is, on the whole, more tendency to insidious forms of 
iritis in gout than in rheumatism. It is also generally be¬ 
lieved that the subjects of gout, or persons whose near 
relatives suffer from it, are particularly subject to glau¬ 
coma ; acute glaucoma was, indeed, the 1 ‘ arthritic ophthal¬ 
mia ” of earlier authors. Hemorrhagic retinitis generally 
due to thrombosis of one or more of the retinal veins is 
also more common in gouty persons than in others; it may be 
single or double, and is to be distinguished from albumin¬ 
uric retinitis. It has also been observed that the children 
or descendants of gouty persons, without being themselves 
subject to gout, are liable, in early adult life, to an in¬ 
sidious form of iridocyclitis (p. 171), which sometimes 
leads to serious consequences ; l both eyes are likely to be 
attacked sooner or later. The cases in this group probably 
seem rarer than they are, from the impossibility in many 
instances of getting a full family history. 

Several different clinical types may be recognized in the 
large group of maladies referred to in this section under 
the name of “ iritis.” Besides cases of pure iritis we meet 
with examples of cyclitis, in some cases with increase, in 

1 Hutchinson : Lancet, January, 1873. 


30 


466 


GENERAL DISEASES OF THE EYE. 


others with decrease of tension; in other groups either the 
sclerotic or conjunctiva are chiefly affected, true “ rheu¬ 
matic ophthalmia ” without iritis; a fourth group, in 
which the pain is disproportionately severe, may be spoken 
of as neuralgic, and these neuralgic cases are marked by 
sudden onset, short duration, and great frequency. In a 
large majority, however, the iris is the headquarters of the 
morbid action. All “arthritic ” eye diseases tend strongly 
to relapse; they usually attack only one eye at a time, 
though both suffer sooner or later; and they are all much 
influenced by conditions of weather, being most common in 
spring and autumn. 

The strumous condition is a fruitful source of superficial 
eye diseases, which are for the most part tedious and re¬ 
lapsing, are often accompanied by severe irritative symp¬ 
toms, but, as a rule, do not lead to serious damage. The 
best types are: (1) the different varieties of ophthalmia 
tarsi; (2) all forms of phlyctenular ophthalmia; (3) many 
superficial relapsing ulcers of cornea in children and ado¬ 
lescents, though not distinctly phlyctenular in origin, are 
certainly strumous; (4) many of the less common but 
very serious varieties of cyclo-keratitis in adults occur in 
connection with lowered health, susceptibility to cold, and 
sluggish but irritable circulation, if not with decidedly 
scrofulous manifestations. 

Leprosy may have its seat in almost any part of the eye, 
but it usually occurs first in the superficial parts, and leads 
to ectropion, with exposure of the cornea, and xerosis of 
the conjunctiva; or there may be a deposit of lepromata 
in the cornea leading to its perforation, and to panophthal¬ 
mitis ; iritis and cyclitis may also occur, and leprous inva¬ 
sion of the retina has also been seen. 

Entozoa sometimes come to rest and develop in the eye 
or orbit. The most common intraocular parasite is the cysti- 
cercus celluloses; it is excessively rare in this country, but 


NEURALGIA. 


467 


more common on the Continent. The cysticercus may be 
found either beneath the retina, in the vitreous, or upon 
the iris, and may sometimes be recognized in each of these 
positions by its movements. The parasite has been success¬ 
fully extracted from the vitreous ; when situated on the iris 
its removal involves an iridectomy. Sometimes it develops 
under the conjunctiva, where I have seen it set up suppu¬ 
rative inflammation. The echinococcus hydatid with mul¬ 
tiple cysts may develop to a large size in the orbit and 
cause much displacement of the eyeball. 

B. Eye disease, or eye symptoms, indicative of local dis¬ 
ease at a distance. 

Megrim is well known to be sometimes accompanied, or 
even solely manifested, by temporary disorder of sight. 
This generally takes the form of a flickering cloud ( scin¬ 
tillating scotoma ) with serrated borders, which, beginning 
near the centre of the field, spreads eccentrically, so as to 
produce a large defect in the field, a sort of hemianopsia; 
the borders of the cloud may be brilliantly colored. It 
is referred to both eyes, and is visible when the lids are 
closed. The attack lasts only a short time, and perfect 
sight returns. In many patients this amblyopia is the pre¬ 
cursor of a severe sick headache, but in others it constitutes 
the whole attack; it scarcely ever follows the headache. 
Less definite and characteristic symptoms (dimness, cloudi¬ 
ness, or muscae), are complained of by some patients. (Com¬ 
pare p. 444.) 

Neuralgia of the fifth nerve, especially of its first division, 
in a few cases precedes or accompanies failure of sight in 
the corresponding eye, with neuritis or atrophy of the disk. 
A liability to neuralgia of the face and head is not infre¬ 
quently observed in persons who subsequently suffer from 
glaucoma. Intense neuralgic pain in the face or head 
sometimes causes dimness of sight of the same eye while 
the pain lasts. The old belief that injury to branches of 


468 


GENERAL DISEASES OF THE EYE. 


the fifth nerve can cause amaurosis is not borne out by 
modern experience, 1 injury to the optic nerve by fracture 
of the skull furnishing the true explanation of such cases. 

Sympathetic ophthalmitis is the only known instance in 
which inflammation of the eyeball is caused by local dis¬ 
ease of an independent part. 

Diseases of the central nervous system may be shown in 
the eve either at the optic disk (papillitis and atrophy) or 
in the muscles (strabismus and diplopia). 

The diseases which most often cause papillitis are intra¬ 
cranial tumors, syphilitic growths, and meningitis. Abscess 
of the brain and softening from embolism and thrombosis 
less commonly cause it, and cerebral hemorrhage scarcely 
ever. 2 Papillitis has been found in a few cases of acute and 
subacute myelitis ; 3 it does not occur in spinal meningitis. 

In a very large proportion (Gowers thinks at least four- 
fifths) of all the cases of cerebral tumor (including syphilitic 
growths) optic neuritis occurs at some period. The severity 
and duration of the neuritis vary much, and probably de¬ 
pend in many cases on the rate of progress, as well as on 
the character of the morbid growth. It not uncommonly 
sets in at no long interval before death, while in other cases 
it is very chronic. There is not much in the character or 
course of the papillitis to help us in the localization of in¬ 
tracranial tumor; and although a very high degree of 
papillitis, with signs of great obstruction to the retinal 
circulation, generally indicates cerebral tumor, there are 
many cases in which the presence of papillitis does not 
help us to decide the nature of the intracranial disease, 
whether tumor, meningitis, or syphilitic disease. 

1 References to many of the earlier cases supposed to prove this relation 
between the fifth and optic nerves are given by Brown-Sequard in Holmes’ 
System of Surgery, third edition, vol. ii. p. 206. 

- A case by Dr. Bristowe in Trans. Ophth. Soc., vol. vi. 1886, p. 363. 

8 Gowers: loc. cit., p. 161; Dreschfeld: Lancet, January 17, 1882; and 
Sharkey and Lawford . Trans. Ophth. Soc., vol. iv. p. 232. 


MENINGITIS. 


469 


Analyzing 96 cases of fatal cerebral tumor, Edmunds and 
Lawford found that optic neuritis was observed in 19 of 41 
cases where the disease was at or toward the convexity (or 
46 per cent.); while it was seen in 41 of 55 cases where the 
disease was chiefly at the base (or 75 per cent.). In 43 cases 
the tumor was either in the basal ganglia or the cerebellum, 
and in 37 of these (= 86 per cent.) optic neuritis occured 
(Transactions of Ophthalmic Society, vol. iv. 172, 1884). 

Tumors also sometimes cause simple optic atrophy by 
pressing upon or invading some part of the optic fibres. 

Intracranial syphilitic disease is a common cause of 
papillitis, the disease being either a gummatous growth in 
the brain, or a growth or thickening beginning in the dura 
mater, or basilar meningitis. The prognosis is much better 
than in cerebral tumors if vigorous treatment be adopted 
early; indeed, in all cases of papillitis where intracranial 
disease is diagnosed, and syphilis even remotely possible, 
mercury and iodide of potassium should be promptly given. 

Meningitis often causes papillitis, but in this respect much 
depends on its position and duration. Meningitis limited 
to the convexity, whatever its cause, is seldom accompanied 
by ophthalmoscopic changes; on the other hand, basic 
meningitis very often causes neuritis. 

Among sixteen cases of injury to the head ending in death 
Edmunds and Lawford never found optic neuritis without 
basic meningitis; while they found no neuritis when the 
damage was limited to the convexity ( Transactions of Ophthalmic 
Society , October, 1886). 

The neuritis in basic meningitis is probably proportionate 
to the duration and intensity of the intracranial mischief, 
being comparatively slight in acute and rapidly fatal cases, 
whether tubercular or not. In tubercular meningitis, 
papillitis is very common, 1 and its occurrence seems especi- 

1 Garlick found it in 23 of 26 fatal cases (Med.-Chir. Trans., vol. lxii.). 
Money (loc. cit.) discovered it in only 16 to 42 fetal cases. Slight papillitis is 
very easily overlooked in delirious or fretful children. 


470 


GENERAL DISEASES OF THE EYE. 


ally related to the presence of inflammatory changes about 
the chiasma (Gowers); and even the neuritis occurring in 
cases of cerebral tumor seems often to be caused by second¬ 
ary meningitis set up by the growth. 1 In a form of men¬ 
ingitis in young children, named by Drs. Gee and Barlow 
“ posterior basic,” optic neuritis is infrequent, though the 
patients often live some little time. When patients recover 
from meningitis the neuritis may pass into atrophy and 
cause amaurosis; such cases are well known to ophthalmic 
surgeons; it is probable that some of them may be instances 
of recovery from tubercular meningitis. In rare cases 
papillitis occurs with severe head symptoms, ending in 
death, but without macroscopic changes in the brain or 
membranes. Microscopical changes in the brain substance, 
justifying the term cerebritis, have been found in one 
such case by Dr. Sutton, and in another by Dr. Stephen 
Mackenzie. 2 It must not be forgotten that optic neuritis 
may be caused by various altered conditions of the blood; 
and that it is occasionally seen without any evidence either 
of central nervous disease or of blood changes. 

Hydrocephalus rarely causes papillitis, but often at a late 
stage causes atrophy of the optic nerves from the pressure 
of the distended third ventricle on the chiasma. Dr. Bar- 
low informs me that he has several times seen a very gross 
form of choroiditis ending in immense patches of atrophy; 
I have recorded one such case and seen others. 

The diseases most commonly causing atrophy not preceded 
by papillitis are the chronic progressive diseases of the spinal 
cord, especially locomotor ataxy. The atrophy in these 
cases is slowly progressive and double, though seldom be¬ 
ginning at the same time in both eyes; it almost always 
ends in blindness, although sometimes not until after many 
years. Similar atrophy sometimes occurs in the early stages 


1 Edmunds and Lavvford : Trans. Ophth. Soc., iii. 1883, p. 138. 

2 Also a case by Dr. Silk, British Med. Jouru., May 26,1883. 


MOTOR DISORDERS OF THE EYES. 


471 


of general paralysis of the insane, but chiefly in cases com¬ 
plicated by marked ataxic symptoms. It is also, but much 
more rarely, seen in lateral and in insular sclerosis. In the 
latter amblyopia with slight neuritic changes is occasionally 
seen, and sight may improve or almost recover after having 
been defective for some time. In cases of homonymous 
lateral hemianopia we find that sometimes the blind half 
of the field is separated from the seeing half by a straight 
line which seems to pass through the fixation point (Fig. 
105); but more commonly this dividing line deviates toward 
the blind half in the central part of the field, thus leaving 
a small central area of perfect vision. Careful observa¬ 
tions show that the dividing line probably never actually 
passes through the fixation point; the explanation of this 
is that fibres from the macular region pass through both 
optic tracts and both hemispheres, so that central vision is 
not destroyed by disease of either tract. 

Motor disorders of the eyes. Some of the more common 
causes of ocular palsy have been already given. It may 
be mentioned here that basic meningitis often causes par¬ 
alysis of one or more of the ocular nerves, with squinting 
(and double vision if the patient be conscious); and, fur¬ 
ther, that the palsy in such cases often varies, or appears 
to vary from day to day. 

Locomotor ataxy and general paralysis of the insane are 
sometimes preceded by paralysis (usually, but not always, 
temporary) of one or more of the eye muscles, causing 
diplopia; and there may for years be nothing else to attract 
attention. The same diseases may also be ushered in by 
internal ocular paralysis. The most frequent variety is 
loss of the reflex action of the pupils to sensory stimula¬ 
tion of the skin and to light, while their associated action 
remains, “reflex iridoplegiawhen shaded and lighted 
thev remain absolutely motionless, but they contract with 
convergence of the eyes, and dilate again when the eyes 


472 


GENERAL DISEASES OF THE EYE. 


cease to converge (“ Argyll-Robertson symptom”). 1 This 
phenomenon is often, though by no means always, associ¬ 
ated with a contracted state of the pupils; hence, the term 
“ spinal miosis” is often but incorrectly used. This re¬ 
flex paralysis of the iris is one of the most valuable of the 
early signs of locomotor ataxy. We do not, however, yet 
know how often it may occur in healthy persons or with¬ 
out eventual spinal disease ; it certainly has comparatively 
little significance in old persons. Recent observations show 
that, at least in general paralysis of the insane, loss of reflex 
dilatation to sensory stimulation of the skin is probably the 
earliest pupillary change. 2 The complementary symptom, 
loss of associated with retained reflex action of the pupils, 
has not been fully studied. Any of the other internal paral¬ 
yses may also in certain cases occur as precursors of ataxy. 
Paralysis of one third nerve coming on with hemiplegia of 
the opposite side may, but does not necessarily, indicate 
disease of the crus cerebri on the side of the palsied third 
nerve. 3 Ophthalmoplegia externa has been already men¬ 
tioned ; it may here be added that cases occur in which 
this condition appears to be “ functional,” in which, at 
any rate, the symptoms come on quickly and pass off com¬ 
pletely, recurring perhaps at a later period; of these cases 
I have seen several in young adults. 

Double ophthalmoplegia externa is the extreme type 
of a large and important class of ocular palsies, to which 
much attention has been given recently, characterized by the 
paralysis of certain movements (usually associated movements 
of the two eyes), not of the muscles supplied by a certain 
nerve. There may be— e. g., loss of power of both eyes to 
look upward (both superior recti), or loss of power to look 
to the right (R. external and L. internal rectus); and yet 

1 Argyll-Robertson : Edinburgh Med. Journ., 1869, p. 703. 

2 Bevan Lewis: Trans. Ophth. Soc., vol., iii. 1883. 

3 For exceptions see Robin: Troubles Oculaires dans les Maladies de 
l’Encephale, 1S80, p. 95. 


HYSTERICAL. 


473 


in the latter case the L. internal rectus, if differently asso¬ 
ciated, as with the R. internal during convergence, may 
act perfectly well. Such associated paralyses are explained 
b) : lesions (usually sclerotic, occasionally tumor) affecting 
the centres for certain combined movements, which are 
more central anatomically and higher physiologically than 
the centres of origin of the nerve-trunks. Cases of paral¬ 
ysis of both third or both sixth nerves, and also of com¬ 
plete ophthalmoplegia, are sometimes due to symmetrical 
coarse disease (syphilitic gummata, for instance) of the 
affected nerve-trunks. The symptoms in all the cases 
referred to in this paragraph may be temporary or perma¬ 
nent, acute or chronic, and caused by various fine or coarse 
anatomical changes; and they are frequently associated 
with other and graver nervous symptoms. It is of great 
importance in cases of multiple and associated ocular 
paralysis to make out if we can whether the symptoms 
point to peripheral disease (disease of nerve-trunks), or to 
disease of the nuclei of origin of the nerves, or to lesion of 
the centres for certain movements. 

Cases of recurrent paralysis of ocular nerves, most fre¬ 
quently of the third nerve, have been described, associated 
with periodic headache on the same side; from the few 
j)ost mortem examinations that have been made, the symp¬ 
toms appear to be due to small, innocent growths in the 
trunk of the affected nerve. 1 

Insular (disseminated) sclerosis is often accompanied by 
nystagmus, characterized by irregularity both of the am¬ 
plitude and rapidity of the movements, and by pallor and 
atrophy of the optic nerves. 

Hysterical eye symptoms. See pp. 277, 379. 

C. Cases in which the eye shares in a local process affect¬ 
ing the neighboring parts. 


1 See Holmes Spicer and Ormerod : Trans. Ophth. Soc., vol. xvi. 


474 


GENERAL DISEASES OF THE EYE. 


In herpes zoster of the first division of the fifth nerve 
the eye participates. When only the supra-orbital or supra¬ 
trochlear branches are attacked the eyeball usually escapes, 
or is only superficially congested. But if the eruption 
occur on the parts supplied by the nasal branch— i. e., if 
the spots extend down to the tip of the nose—there is usu¬ 
ally inflammation of the proper tissues of the eyeball 
(ulceration or infiltration of cornea and iritis); for the 
sensitive nerves of the cornea, iris, and choroid are de¬ 
rived, through the long root of the ophthalmic ganglion, 
from the nasal branch. Occasionally the eye suffers, how¬ 
ever, when the nasal branch escapes. The pain and swell¬ 
ing of the herpetic region are often so great that the attack 
gets the name of “ erysipelas.” In rare cases atrophy of 
the optic nerve and paralysis of the third and other neigh¬ 
boring nerves occur with the herpes. 1 

In paralysis of the first division of the fifth the cornea 
and conjunctiva are anaesthetic ; the cornea maybe touched 
or rubbed without the patient feeling at all. In many 
cases ulceration of the cornea, usually uncontrollable and 
destructive in character, takes place. This is probably due 
to anaesthesia of the cornea ; the loss of sensation (1) allows 
injuries and irritations to occur unperceived, and (2) by re¬ 
moving the reflex effect of the sensory nerves on the calibre 
of the bloodvessels, permits inflammation to go uncontrolled. 

In paralysis of the facial nerve the eyelids cannot be 
shut, and the cornea remains more or less exposed. When 
a strong effort is made to close the lids the eyeball rolls 
upward beneath the upper lid. Epiphora is a common 
result of facial palsy. Severe ulceration of the cornea 
may result from the exposure. 

Paralysis of the cervical sympathetic causes some nar¬ 
rowing of the palpebral fissure from slight drooping of the 

1 A useful paper on facial herpes with many references by Mr. Jessop, is 
published in vol. vi. of the Ophthalmological Society’s Transactions, 1886. 


EX 0 PHTH A LMIC G OITRE. 


475 


upper lid, apparent recession of the e) T e into the orbit, and 
more or less miosis from paralysis of the dilator of the 
pupil (p. 377). No changes are observed in the calibre of 
the bloodvessels of the eye, or in the secretion of tears. 
The pupil is said to be less contracted after division of the 
sympathetic trunk than when the trunk of the fifth (and 
with it the oculo-sympathetic fibres) is cut, and knowledge 
of this may be now and then useful in diagnosis. 

In exophthalmic goitre (Graves’ disease, Basedow’s dis¬ 
ease) the most prominent symptoms are protrusion of the 
eye, excited action of the heart, enlargement of the thy¬ 
roid, and certain nervous phenomena; the protrusion is 
almost invariably bilateral, though not infrequently 
greater on the right side. The upper lids do not follow 
the eyeball in looking dowu (v. Graefe’s sign); infre¬ 
quency of involuntary winking (Stellwag’s sign) and 
abnormal width of the palpebral aperture are also found. 

In severe cases the proptosis may be so great as to pre¬ 
vent full closure of the lids, and in these dangerous ulcera¬ 
tion of the cornea is to be feared. In such cases it is bene¬ 
ficial to shorten the palpebral fissure by uniting the borders 
of the lids at the outer canthus, or even to unite the lids in 
their whole length (p. 387). No changes are present in 
the fundus, except occasional dilatation of arteries and 
spontaneous arterial pulsation. The seat of the lesion 
causing this peculiar malady is not yet known; it was 
formerly supposed to be due either to some morbid con¬ 
dition of the sympathetic, or to disease of the heart; there 
is more to support the view that it is due to a primary 
localized lesion of the medulla oblongata. More recent 
observations have tended to show that all the symptoms 
may be caused by excessive formation of thyroid secretion 
and by its absorption by the blood. 1 

1 See discussion, Carlisle meeting of British Medical Association, British 
Med. Journ., 1896, ii. p. 893. 


476 


GENERAL DISEASES OF THE EYE. 


Erysipelas of the face sometimes invades the deep tissues 
of the orbit, and causes blindness by affecting the optic 
nerve and retina; on recovery the eye is found to be blind, 
and the ophthalmoscope shows either simple atrophy of the 
disk, or signs of past retinitis also. Other forms of orbital 
cellulitis may lead to the same result. 

Disease of the nose and adjacent sinuses is in certain 
cases a most important cause of ocular disease. Phlycten¬ 
ular ophthalmia, particularly when rebellious to treatment, 
will often be found to accompany a chronic rhinitis. The 
treatment of the nasal mucous membrane, conjoined with 
the local and general measures usually recommended, leads 
to the most prompt and complete recovery. 

In many cases of lachrymal obstruction an examination 
of the nose will show that the duct has been closed at the 
lower extremity, either by pressure of hypertrophied or 
distorted turbinals, the tension of cicatricial bands, or by 
chronic inflammation in the adjoining membrane. The 
obstruction is most perfectly and readily relieved by direct 
treatment of the nasal condition. 

Not rarely, orbital cellulitis is excited by disease of one 
or more of the cavities surrounding it. At times the in¬ 
flammatory process is so great that phlegmon of the orbit 
and extreme proptosis of the eyeball are induced. At 
other times, however, especially in cases of ethmoiditis, the 
symptoms are much milder, the most marked being the 
swelling at the inner canthus and the outw r ard displacement 
of the globe. 

Disorders of the teeth, though rarely, may also induce 
changes, structural as well as functional. Among the latter 
may be mentioned restriction in the range of the accom¬ 
modation and amblyopia, while metastatic choroiditis and 
iritis have followed dental abscesses. 


Note on the Teeth in Inherited Syphilis, with 


TEETH IN INHERITED SYPHILIS. 


477 


Description op Fig. 181. None of the first set of teeth 
me characteristically altered, though the incisors frequently 
decay early. 


Fig. 181. 






In the permanent set only two teeth, the central upper 
incisors, are to be relied upon; but the other incisors, both 
upper and lower and the first molars, are often deformed 





478 


GENERAL DISEASES OF THE EYE. 


from the same cause. The characteristic change in the 
central upper incisors appears to depend upon defective 
formation of the central lobe of the tooth (Fig. 181, 2, 5, 
and 6). Soon after the eruption of the tooth this lobe 
wears away, leaving at the centre of the cutting edge a 
vertical notch (No. 1). If the cause have acted so in¬ 
tensely as entirely to prevent the development of the cen¬ 
tral lobe, we find, instead of the notch, a narrowing and 
thinning of the cutting edge in comparison with the crown, 
and this, according to its degree, produces a resemblance 
to a screw-driver, or to a peg (Nos. 3 and 4). The teeth 
are also usually too small in every dimension, so that the 
incisors are often separated from one another by consider¬ 
able spaces. In extreme cases all the incisors are peggy 
and much dwarfed. The changes are usually symmetrical, 
but No. 5 shows one tooth typically deformed and the 
other normal. 

Fig. 181 (No. 7) shows in an extreme degree the changes 
due to absence of enamel from the permanent teeth (“ mer¬ 
curial,” “ stomatitic,” “ strumous,” and “ rickety” 

The change occurs in lines running horizontally across the 
whole set of permanent incisors and canines. When slight 
it affects only the part near the edge, the enamel beginning 
as a sudden terrace or step a little distance from the edge; 
in bad cases several such “ terraces” are present, and the 
whole tooth is rough, pitted, and discolored. The first 
permanent molars show a corresponding change on the 
grinding surface. It is this imperfection that is found 
present in nearly all cases of lamellar cataract (p. 193), 
though the dental condition is common enough in persons 
without that or any other form of cataract. 



[SUPPLEMENT, 


THE PRACTICAL EXAMINATION OF RAILWAY EM¬ 
PLOYES AS TO COLOR-BLINDNESS, ACUTENESS OF 
VISION, AND HEARING, INCLUDING THE SYSTEM 
ADOPTED IN 1881 BY THE PENNSYLVANIA RAIL¬ 
ROAD, AND STILL IN USE. 

By William Thomson, M. D., 

EMERITUS PROFESSOR OF OPHTHALMOLOGY IN THE JEFFERSON MEDICAL 

COLLEGE, PHILADELPHIA. 

In accordance with a wish expressed by the President 
in 1879, that I should suggest some practical method for 
the examination of the employes of the Pennsylvania 
Railroad as to their ability to see the colored signals by day 
and night used in the service, I devoted much time to the 
subject, in an effort to overcome the following difficulties: 

1. To ascertain whether each man possesses sight enough 
to see form at the average distance, and range of vision to 
enable him to see near objects well enough to read written 
or printed orders and instructions. 2. To learn if each 
man has color-sense sufficient to judge promptly and gov¬ 
ern his actions by day or night, by the colors in use for 
signals. 3. To determine the ability of each man to hear 
distinctly. 

The difficulties to be overcome were found in the magni¬ 
tude of the task, involving the examination of thirty-five 
thousand men then in the service, with the necessity of 
extending it to all who might be hereafter employed, dis¬ 
tributed over thousands of miles of road, and in the 

(479) 



480 


SUPPLEMENT. 


absence of ophthalmic experts in sufficient number, pos¬ 
sessing enough special training to fit them to decide with 
precision the points in issue. 

It soon became apparent that some system would be 
needed that could be put in force by each Division Super¬ 
intendent, acting through intelligent employes, under the 
general supervision of one or more ophthalmic surgeons 
of recognized skill, to whom all information collected 
could be transmitted, and who would be able to decide all 
doubtful cases, and thus protect the road from any danger 
arising from incapable employes, and save good and faith¬ 
ful men from the evil of being discharged from the com¬ 
pany’s service, or prevented from being employed on other 
roads on insufficient grounds. 

It was believed that the facts could be collected by non- 
professional persons, and could be so clearly presented to 
the Division Superintendent and to the ophthalmic expert 
as to enable a perfectly correct decision to be made in 
every case; and that men fit for service would be recog¬ 
nized, while those deficient in sight, color-sense, or hear¬ 
ing, could be referred to the expert if they so desired, or 
transferred to places in the service where their defects, if 
not remediable by treatment, could do no harm either to 
the road or to the public. 

Such a system was submitted to the General Manager of 
the Pennsylvania Railroad some months later, and was 
perfected by the labors of a special committee of the Society 
of Transportation Officers in conjunction with the writer. 
The entire method was, furthermore, then submitted to a 
practical experimental test extending over nearly two 
thousand men, employed as conductors, engineers, firemen, 
and brakemen, and the results have satisfied the committee 
and myself that our object has been fully attained, and 
that the system proposed may now be put in force with 
confidence in its practical utility. As an evidence of this, 


EXAMINATION OF RAILWAY EMPLOYES. 481 


I may cite two complete detailed reports, including 1383 
men in all. The blanks upon which the original entries 
were made have all been submitted to me, and they satisfy 
me that the results in the summary of each of these excel¬ 
lent reports maybe confidently accepted, and thus we have 
become acquainted with the fact that there were in the 
service of the Pennsylvania Railroad, of the 1383 men 
examined, 246 men deficient in the full acuteness of vision, 
55 absolutely color-blind, and 21 defective in hearing. 

In one of the reports, an examination not included in 
the instructions from the committee was made with colored 
flags and colored lights by night, and 13 men failed to be 
able to recognize them from a total of 24, who were color¬ 
blind to the test used for its detection; but I have little 
doubt whatever that the entire number of color-blind, viz., 
55, would also fail under a carefully-devised system of tests 
by the usual railroad signals. 

The entire number reported as defective in color-sense, 
4 T \ per cent., is up to the average, as reported by the best 
authorities in its percentage; but those absolutely color¬ 
blind, and hence unable to distinguish between a soiled 
white or gray and green, or a green and red flag, are fully 
4 per cent.; and this proves that the instrument employed 
in this part of the examination has met our expectations 
fully. 

As this was the point about which I had most doubt, a 
word or two of explanation may be proper, more especially 
as many great authorities declare that no examination for 
color-blindness should be accepted unless made by profes¬ 
sional specialists. 

The examination for color-blindness now generally 
accepted and proposed by Prof. Holmgren consists in 
testing the power of a person to match various colors 
which are most conveniently used in the form of colored 
yarns. Usually about 150 tints are employed, in a con- 

31 


482 


SUPPLEMENT. 


fused mixture, and three test colors, viz., light green , rose 
or purple, and red , are placed in the foregoing order be¬ 
fore the person examined, who is directed to select similar 
colors from the mass. The examiner sits then in judg¬ 
ment, and decides whether the color-sense is perfect from 
the selections made, or from those not made, or from them 
both, and from the prompt or hesitating manner of the 
examined. It has been our effort to render this more 
simple, and to so arrange the colors that they may be 
identified by some number, so that an expert, although 
absent from the scene, would know by these numbers the 
exact tints selected, and thus be fully competent to declare 
from them the color perception of any person whose record 
had been properly made. From theory based upon scien¬ 
tific knowledge, and from much experience, I was able to 
arrange an instrument that would have the real colors and 
those usually confounded with them, “ confusion colors,’’ 
placed in such relations to each other, and so designated by 
numbers, as to make an examination for color-blindness 
possible by a non-professional person, who could conduct 
the testing, record it properly, and transmit it to an expert 
capable of deciding upon the written results. Hence there 
is no departure from the system of matching tints already 
established, the only novelty being in reducing the number 
of colors to those similar to the test colors, and to those 
usually chosen by color-blind persons, and so identifying 
them as to enable an absent expert or superintendent to 
know precisely what colors had been selected to match 
the test colors. 

The theory of the instrument (consisting of a stick with 
the yarns attached, see Plate), is that color-blindness is 
most promptly detected by using the light green test-skein, 
and asking that it be matched in color from the yarns on 
the stick, which are arranged to be alternately green and 
confusion colors, and are numbered from one to twenty, 


PLATE JV. 





£»-M. £u. ] W, vL S3 








hnm 




'* l>ll »y >) *^^ niw wm ^, <i 

































EXAMINATION OF RAILWAY EMPLOYES. 483 


the person being directed to select ten tints, and the ex¬ 
aminer being required to note the numbers of the tints 
chosen. It will be seen that the odd numbers are the 
green, and the even ones the confusion colors, and, that 
if a person has a good color-sense, his record will exhibit 
none but odd numbers; while, if he is color-blind, the 
mingling of even numbers betrays his defect at a glance 
to the supervising expert or superintendent. 

There are forty tints on the stick, and the first twenty 
are given to the detection of color-blindness, using the 
green-test , and if the color-sense is deficient, it will surely 
be revealed. 

To distinguish, however, between green-blindness and 
red-blindness, the rose-test is used, and those color-blind 
will select indifferently, either the blues intermingled with 
the rose, between figures 20 and 30, or perhaps the blue- 
green or grays from 1 to 20, and thus reveal their defect, 
and establish either green- or red-blindness. 

Finally, the reel-test corroborates these results, and satis¬ 
fies the most sceptical of color-defect, when the “ confusion 
tints ” or even numbers between 30 and 40 are selected. 

On a suitable blank these figures are placed in the order 
of examination, and a glance of the eye reveals the color- 
sense of the person examined; since, if anything but odd 
numbers are chosen, there is a defect; or if, with test one, 
anything beyond 20 is chosen; or if, with test two, any¬ 
thing but odd numbers between 20 and 30; or, with test 
three, anything but odd numbers between 30 and 40. The 
color-skeins can readily be changed in the instrument, if it 
should be found desirable. 

It is theoretically and practically a fact that the tints as 
arranged on the instrument look quite the same in color to 
color-blind persons, and that those having a perfect color- 
sense can thus form an idea of this infirmity. If, then, 
green and gray are indistinguishable, and green and red, 


484 


SUPPLEMENT. 


when of the same depth of color, seem to be entirely the 
same to the color-blind, it needs no opinion from a scien¬ 
tific expert to convince the manager of a railroad that it 
would be most dangerous to place the lives of people under 
the guidance of an engineer who could not distinguish, if 
green-blind, between a soiled white and a green flag, or 
between a green and red flag, or other signal of these 
colors. 

It is a fact that some of the color-blind promptly give 
the proper names to the flags, and answer correctly, when 
asked what they would do in presence of such signals; but 
it must be remembered that they may see perfectly, and 
have always had some perception of these colors, and do 
give them their conventional names, perhaps, but that they 
are unable to distinguish them at once and infallibly, and 
that it will only require a further extension of our method 
of testing to demonstrate the inability of persons color¬ 
blind to our examination to recognize the signals, by day 
or night, which are now depended upon to prevent acci¬ 
dents of the gravest character. This must be done by de¬ 
manding that the signals be matched, and not named, and 
is incorporated in the instructions herewith submitted, so 
that the tints which color-blind men select with the rail¬ 
road signals may hereafter be known and recorded. 

My conclusions from a study of the subject in connection 
with the railway service are : 

1. That there are many employes who have defective 
sight, caused either by optical defects, Avliich are, perhaps, 
congenital, and which might be corrected with proper 
glasses, or due to the results of injuries or diseases of the 
eyes, remediable or not by medical or surgical treatment. 

2. That one man in twenty-five will be found color-blind 
to a degree to render him unfit for service where prompt 
recognition of signals is needed, inasmuch as color-blind¬ 
ness for red and green renders signals of these colors indis- 


EXAMINATION OF RAILWAY EMPLOYES. 485 


tinguishable. It is a fact in physiological optics, however, 
that yellow and blue are seen by those color-blind for red 
and green, and that yellow-violet blindness is so rare that 
it might lead to the use of these yellow and blue colors, in 
preference to red and green, wherever possible. 

3. That color-blindness, although mainly congenital and 
incurable, is sometimes caused by disease or injury, and 
that precautions might be needed to have either periodical 
examinations or to insist upon it in cases where men have 
suffered from severe illness or injury, or when they have 
been addicted to the abuse of tobacco or alcohol. 

4. That the method, when adopted, will enable the 
authorities to know exactly how many of their employes 
are “satisfactory in every particular’’ as to sight and 
hearing; and that the examination will have the further 
value of making the division superintendents acquainted 
with the general aptitude of the men in their divisions as to 
general intelligence. 

5. That the entire examinations can be made at the rate 
of at least six men an hour; while that for color-sense 
alone can be done in a very few minutes for each man by 
an intelligent employe. 

6. That to secure the confidence of the employes and of 
competent scientific critics, as well as of the public gener¬ 
ally, it is advisable to have some official professional 
specialist to whom all doubtful questions could be referred, 
and who should be held responsible for the accuracy of the 
instruments, test-cards, etc., to be put in use, and who 
should have general supervision of the entire subject of 
sight, color-sense, and hearing. 

7. That from the impossibility of subjecting the immense 
number of employes on our large railways to the inspection 
of the few surgical experts available, and to secure the ex¬ 
amination of those hereafter to be employed, some system 
of testing by the railway Superintendents has become a 


486 


SUPPLEMENT. 


necessity, and it is believed that the one prepared will 
answer the purpose. 

By request, these views were communicated to the proper 
officials of the Pennsylvania Railroad Company, and on 
July 1, 1881, I received a communication from the gen¬ 
eral manager, from which I make the following extract: 

“ Dear. Sir : I beg leave to inform you that the appa¬ 
ratus invented by you, and the rules and regulations enti¬ 
tled ‘ Instructions for examinations as to vision, color-sense, 
and hearing,’,.prepared by a committee of transportation 
officers of the Pennsylvania Railroad and yourself, for the 
use of our officers in examining employes for defects of 
sight and hearing, were laid before the Board of Directors, 
who approved and adopted them, and authorized me to put 
them into effect, subject to such changes from time to time 
as experience may prove to be necessary for the proper 
working of the system. 

“ In putting these rules into effect, I take pleasure in 
designating you as the expert to whom, under the rules, 
such cases shall be referred as may require the judgment 
of an expert.” 

Pennsylvania Railroad Company’s Instructions 
for Examination of Employes as to Vision, 
Color-blindness, and Hearing. 

Instructions for examination as to vision, color-blindness, 
and hearing. The examination will be made as to vision, 
color-sense, and hearing, and the following apparatus will 
be used: 

1. A card or disk of large letters for testing distant 
sight. 2. A book or card of print for testing sight at a 
short distance. 3. An adjustable frame for supporting the 
print to be read, with a graduated rod attached for meas¬ 
uring the distance from the eye while reading. 4. A spec- 


EX A MINA TION OF RAIL WA Y EM PL 0 YES. 48 7 


tacle frame for obstructing the vision of either eye while 
testing the other. 5. An assortment of colored yarns for 
testing the sense of color. 6. A watch with a loud tick 
for testing the hearing. 7. A book or set of blanks for 
recording the observations. 8. A copy of an approved 
work on “ color-blindness.” 

Acuteness of vision. For distant visiou, place the test- 
disk or card in a good light twenty feet distant, and ascertain 
for each eye separately the smallest letters that can be read 
distinctly, and record the same by the number of that series 
on the card. 

Range of vision. For near vision, ascertain the least 
number of inches at which type D = 0.5 or 1J, can be 
read with each eye, and record the result. 

Field of vision. Let the examiner stand in front of the 
examined, at a distance of three feet, and directing the 
examined to fix his eyes on the right eye of the examiner, 
and keep them so fixed, let the examiner extend his arm 
laterally, and opening and shutting his hands, let him by 
questions satisfy himself that his hands are seen by the 
examined without changing the direction of the eyes; re¬ 
cording the result as good or defective, as the case may be. 

Color-sense. Three test-skeins—A, light green ; B, rose; 
C, red—will be used with the colored yarns attached to 
the stick ; of the latter there are forty tints, numbered 
from 1 to 40, and arranged in three sets—a, b , and c — 
of which the odd numbers correspond to the colors of the 
test-skeins, while the even numbers are different or “ con¬ 
fusion colors.” 

The first set is to test for color-blindness ; the second to 
determine whether it be red- or green-blindness, and the 
third to confirm the opinion formed from the first or 
second test. 

Place the test-skein A at a distance of not less than three 
feet, and without naming the color, direct the person exam- 


488 


SUPPLEMENT. 


ined to name the color, and to select from the first twenty 
tints, or set (a), of the yarns on the stick, ten tints of the 
same color as skein A, stating that they do not match, but 
are different shades of the same color. Record the number 
of the tints so selected. Do the same with skeins B and C, 
using for B the tints from 21 to 30, and for C the tints 
from 31 to 40. If the odd numbers are selected readily, 
the examination may be gone over very quickly. 

When color-blindness is detected, any one of the even 
numbers or “confusion colors” mav be used as a test- 
skein, and the man may be directed to select similar tints, 
when he will most probably choose odd numbers, which 
should be recorded, stating the number on the stick of the 
“confusion color” used for a test, and then giving the 
numbers chosen to match it. 

Then a soiled white flag should be shown, and the man 
be directed to select tints to match it, which should be 
recorded; next a green, and finally a red flag. 

All of the particulars are to be recorded as the examina¬ 
tion proceeds, not leaving it to memory. Use the numbers 
in recording. The letters indicating the set need not be 
used. Note whether the selection is prompt or hesitating 
by a distinct mark after the proper word on the blank 
form. When deficient color-sense is discovered, and varia¬ 
tions in the mode of testing are made by the examiner or 
examined, they should be noted under remarks, or on a 
separate sheet to be referred to, if the blank has not room 
enough. 

Hearing. Note the number of feet or inches distant 
from each ear at which a watch, having a tick loud 
enough to be heard at five feet, is heard distinctly, using 
a watch without a tick, or a stop-watch, to detect any 
supposed deception; and the number of feet at which 
ordinary conversation is heard, and the numeral figures 
can be repeated when spoken. 


EXAMINATION OF RAILWAY EMPLOYES. 489 


Explanations. The test-disk contains letters, numbered 
from 20 (xx), or D = 6, to 200 (cc), or D = 60. Those 
measuring three-eighths of an inch, and numbered 20 (xx) 
or D = 6, are such as a good eye of ordinary power sees 
distinctly twenty feet or six metres distant. If a man sees 
distinctly only those marked C (or 100), his acuteness of 
vision, V., is equal to jjy$, or -J-. If he sees to XX (or 20), 
then V. is equal to or 1, and his sight is up to the full 
standard. This mode of statement indicates the relative 
value of the sight examined, and should be used in the 
records. If one eye is or 1, and the other not less than 
to or with or without glasses, the sight may be con¬ 
sidered satisfactory. 

The power of discerning small objects at the reading dis¬ 
tance is tested by the small print, and good sight may be 
assumed if one eye can see at twenty inches the matter 
marked II or D = 0.5, while the other distinguishes not 


Fig. 182. 





490 


SUPPLEMENT. 



Dr. Thomson’s revolving disk of test-types consists of two superimposed 
disks of cardboard, twelve inches in diameter, so fastened by their centres 
to a square of cardboard which supports them that the front disk remains 
fixed, while the back disk may be made to revolve. Near the bottom of 
the front disk is one of Snellen’s test-letters, large enough to be recognized 
at 60 meters = 200 feet; over this one for 36 meters = 120 feet. Above this is 
an opening through which the letters on the back disk may be seen. On 
the back disk test-letters arranged in five radiating rows, either of which 
may be brought to the aperture, making a series of test-types from 6 meters, 
or 20 feet to 60 meters, or 200 feet. The first figure shows the complete test, 
the second shows the back or revolving disk. By this arrangement, the 
person tested is prevented from becoming too familiar with the sequence 
of the letters he is asked to recognize. 

less than 4£ or D = 1.5. The small print should then be 
brought to the point of nearest vision for each eye, and 
that point mentioned in inches. A good eye should be able 
to read No. 1 \ at twenty inches, and have a range of vision 
up to ten inches. 

The color-test will indicate whether the man is deficient 















EXAM IN A TION OF RAIL WA Y EMPLOYES. 491 


in color-sense. The colors are arranged in three sets, one 
of 20 and two of 10 each—the odd numbers are the colors 
similar to the test-skeins, and the even numbers are the 
“ confusion colors,” or those which the color-blind will be 
likely to select to match the sample skeins or colors shown 
him. The first 20 (a) numbered from 1 to 20, have green 
tints for the odd numbers or test-colors. In the second 
( b ), 21 to 30, the test-colors are rose or purple, a combina¬ 
tion of red and blue; and in the third (c), 31 to 40, they 
are red. Ordinarily the test will be with each set sepa¬ 
rately, but the whole 40 may be employed on any test- 
skein. Anything but green matched with green indicates 
a defect in the color-sense, for which use set (a). 

The test with the second set indicates whether red or 
green blindness exists. The odd numbers from 21 to 30 
are purple. If either of these is matched with test-skein 
B, nothing is indicated, as they must appear alike to a 
color-blind person ; but if blue is chosen, red-blindness is 
indicated, and if green, then green-blindness is established. 

The third set (c) is scarcely needed, but may be used in 
confirmation of, or in connection with, the last, as to red 
or green defect. 

When the numbers of the tints selected are recorded in 
the proper blank, color-blindness will be indicated in those 
instances where even numbers appear, and suspicions will 
arise where numbers beyond 20 are used with test-skein A., 
and under 21 or beyond 30 with B, and below 31 with C. 

Further tests should be made of those found to be color¬ 
blind with the usual signal flags, requesting them to name 
each color, shown singly, and to match the colors of them 
from the tints on the stick, and with colored lamps; and 
finally to state what they understand them to mean as sig¬ 
nals. 

It will be well not to dwell on the examination of a man 
found to be defective in color-sense or in vision, but to pass 


492 


SUPPLEMENT. 


over each examination with the same general care, and 
afterward send for those giving indications of defects, to 
come in singly for fuller examination. The examination 
should be private as far as practicable, especially excluding 
persons who are to be subsequently examined. 

Inability to name color accurately, or to distinguish 
nicely as to difference in tint, is not to be taken as an 
evidence of color-blindness. 

In testing as to hearing, if the watch used can be heard 
at five feet distant, and the person examined hears it only 
at one foot, his hearing would be 1-5, and may be so re¬ 
corded in fractions. Conversation in an ordinary tone 
should be heard at ten feet. 

It should be understood that all employes examined fail¬ 
ing to come up to the requirements of the above standard 
shall be accorded the benefit of a professional examina¬ 
tion. When acuteness of vision is below the standard 
adopted, it may be possible to restore full vision by proper 
glasses, when it is due to optical defects known as near¬ 
sight, far-sight, or astigmatism, or by other medical or 
surgical treatment, and useful men may then be retained 
in the company’s service. 

In order to show how the Pennsylvania Railroad Com¬ 
pany keeps its records of these examinations we submit the 
following fac-simile of an actual blank used in detecting a 
case of color-blindness: 


EX A MINA TI ON OF RAIL WA Y EM PL 0 YES. 493 


West Jersey Railroad Company. 

Camden, January 19, 1883. 

Examination of sight and hearing of James A. Morris, aged 
twenty-two, employed as locomotive fireman, applicant for 


Acuteness of Vision. 

Range of Vision. 

The number of the 
Series seen at twenty 
feet distant: 

Right eye, 20-30 
Left eye, 20-20 

Least number of 
inches at which type 
D—0.5 in test-type 
pamphlet can be read. 

Right eye, 
inches. 

Left eye, 
44 inches. 

Field of Vision. 

Good or defective . . . Good. 

Color-seme. 


Test-skein 
submitted. 

Name 

given. 

Numbers selected to match. 

A—Green 
B—Rose 
C—Red 

Green 

Red 

Red 

3, 26, 24, 7, 11, 22, 15, 5, 1, 17, 28, 9, 
37, 33, 29, 12, 39, 31, 21, 35, 25, 27, 
37, 33, 31, 35, 23 

19, 30,13 
23 


Second Color-test. 


Third Color-test. 

Number 

Name 

Numbers 


Flag 

Name and 

Numbers 

shown. 

given. 

selected. 


shown. 

use given. 

selected. 

24 

Green. 

26, 22 


Soiled 

Safety, 

2, 4, 6 




white. 

white. 


39 

Yellow 

Could find 


Soiled 

Caution, 

36, 38 


red. 

no match. 


green. 

green 


30 

Blue. 

26 


Soiled 

Danger, 

37, 33, 31 





red. 

red. 



Selection Prompt or Hesitating: 


Prompt. 














































494 


SUPPLEMENT. 


Hearing. 


Right Ear. 


Left Ear. 

Watch. 

Conversation. 


Watch. 

Conversation. 

8 feet. 

20 feet. 


8 feet. 

20 feet. 


Remarks. 

Escaping steam prevented watch-test. 

J. J. Burleigh, Examiner. 

Acuteness, right eye defective. Bange, good. Field, good. 
Color-sense, defective. Hearing, see Remarks. 

Jos. Crawford, Superintendent. 

Note. —Those approved, marked “Appd.” 

Those not approved, marked “Not Appd.” 


The color-blind and those found defective in sight and 
hearing were soon removed from positions of danger. The 
entire system has been continued on the Pennsylvania Rail¬ 
road since 1881, giving full satisfaction, and is now used 
as a barrier before every new applicant, to protect the road 
from the admission of dangerous men. It has been adopted 
by the Philadelphia and Reading Railroad Company and 
by others, as is shown by the replies received in response 
to a circular sent to a hundred of the most important 
railroad corporations of this country, controlling 129,970 
miles, in 1894, asking if examinations were made as to 
color-blindness. Thus it was found in 1894 that 

Twenty-four using Dr. Thomson’s test controlled 38,786 miles. 
Eleven using other methods controlled . . . .15,679 “ 
Thirty-one making no test controlled .... 29,428 “ 

Thirty-four making no reply controlled . . . 46,077 “ 

Sixteen other roads having control of 12,947 miles have 
also adopted my color-stick, thus making a grand total of 

















EX A MINA TION OF RAILWAY EMPLOYES. 495 


51,733 miles protected by this test out of 142,917 covered 
by the investigation. The total number of roads included 
is 116 ; of these 40 use my color-stick ; 11 use other color- 
tests, mainly Holmgren’s; 31 use none; 34 have made no 
response. The entire system has also been in use on the 
Midland and on the London and Southwestern in England. 

The example of the Pennsylvania Railroad has accom¬ 
plished much good, but there is yet much to be done to 
bring all the roads in the country under the protection of 
some efficient method of testing, to secure both the roads and 
the public against loss of life and property from these well- 
known defects of their employes. The total mileage of the 
country, 1894, was 175,233, and there were about 1,000,000 
employes. 

As the result of much experience, and after a study of 
the entire subject, I suggested in 1894 some improvements 
that would enable a new test to be used in connection 
with the color-stick or as a substitute for it. The color- 
skeins of this New Wool Test have been most carefully 
selected, and a standard set will be kept, so that renewals 
may be made of the entire set or of those skeins that may 
become faded, soiled, or lost. The new set consists of a 
large green and a large rose test-skein, and forty small 
skeins, each marked with a bangle having a concealed 
number, extending from 1 to 40, placed in a double box, 
so arranged as to keep the two series apart and to permit 
each to be exposed upon a table in a confused mass. The 
stick is dispensed with, as giving too fixed an arrangement 
to the skeins and not enough confusion, although the skeins 
can be readily removed from their hooks and changed in 
position for this purpose, and should be so used. 

The large green skein being placed near by, the small 
skeins, from 1 to 20, are exposed in good daylight, and the 
employe under examination is directed to select ten shades 
of the same color of the test-skein. One with normal vision 


496 


SUPPLEMENT. 


will choose promptly and with ease the ten greens with odd 
numbers on the bangles. A color-blind person will hesi¬ 
tate, and his selections will contain some even numbers, 
and the confusion colors will be shades of brown, etc., con¬ 
taining some red, or shades of gray, and will indicate the 
color-defect. These figures are to be recorded on a blank, 
and the twenty skeins are to be removed. The large rose- 
skein is then used and the examination repeated in like 
manner with skeins numbered from 21 to 40, and the re¬ 
sult recorded. The confusion skeins, which have even 
numbers, are blue, green, and gray. From the selections 
made by the man found color-defective by the green test, 
we are able to decide the character of his color-blindness. 
Those selecting blues are red-blind; those taking greens 
and grays are green-blind, according to the nomenclature 
of Holmgren. There are ten roses and ten confusion colors 
in the second series. 

The red test-skein of the stick, with its confusion-colors, 
is omitted entirely, and the test is made to conform more 
strictly with Holmgren’s method, while the examiner is 
also provided with forty questions of decisive clearness. 
Greater scientific accuracy is obtained by this method, 
and with the careful selection of these confusion colors I 
now regard this system as an improvement upon the stick, 
and as a safer and more simple method to be used by a 
non-professional examiner. The blank will also give to 
the division superintendent or to any supervising surgical 
expert a more simple report of the examination. The 
yarns are to be kept from the light in the double box, one 
side of which is colored green and the other rose, to aid the 
examiner in keeping the series separate and to save time. 
The test will also be a valuable addition to those to be used 
by surgical experts and ophthalmic surgeons. 

When used in addition to the stick the second and third 
color-tests may be omitted. 


EXAMINATION OF RAILWAY EMPLOYES. 497 


Directions for the Use of this Test. 

1. Examine only one eye at a time by covering the other 
eye with a handkerchief, or some other means that will 
exclude it from vision. 

2. Spread a white cloth, like a towel, on a table in a good 
light. 

3. Take out all the worsteds from the green part of the 
box and put them on the cloth at random. 

4. Take from this heap the large light green test, which 
is marked “A,” and laying it to the side in a good light 
direct the man to select 10 skeins from the heap. Tell 
him that these are not to be exactly like it in every respect, 
but that they are to be of the same color, only a little 
lighter or darker in shade. 

5. Write down on your blank the numbers of the 10 
skeins selected by the man to match the test-skein A. If 
only odd numbers appear which he selected promptly, then 
he is not color-blind ; but if even numbers have been chosen, 
he must be more or less color-blind. 

6. Ask him the name of the color he has been matching, 
or any other worsted, and register his answer on the blank. 

7. Remove now all the worsteds and put them back into 
the green part of the box. 

8. Now take out the second test and expose it on the 
table in the same way as before. 

9. Show him the large rose-colored test-skein, marked 
“ B,” and ask him to match this with 10 worsteds in the 
same sense as before with the first test. 

10. Register his 10 selections on the blank. Now any 
even numbers selected betray and determine definitely his 
color-blindness. If the man selects blues, with the test- 
skein B, he is red-blind ; if he selects grays or greens, he is 
green-blind. 


32 


Examination of sight and hearing of 
., employed as. 


498 


SUPPLEMENT. 


Ci 

00 


















































































earing. 


EX A MTNATTON OF BA TLWA Y EMPLOYES. 


499 




G 

a> 

ft 


G 
o 
• < 

c3 

w 

S-i 

<u 

> 

g 

o 

O 


ft! 

o 

•*-> 

CS 


t-, 

oj 

w 

*2> 

XI 

bo 

5 


C 

O 

-♦-» 

ej 

tn 

s- 

a> 

>■ 

a 

o 

O 


X3 

o 

— 

c3 


co 

C? 




Kl 


n 

ft 

ft 

<1 

o 

£ 


'G 

D 

M 

M 

oj 

S 

'O 

a> 

> 

o 

«-i 

ft 

ft 

oj 

-*-» 

O 

G 

© 

tn 

O 

ft 

H 


T3 

ft 

ft 


ft 

© 

ft 

(-< 

aj 

a 

ft 

© 

> 

o 

ft 

ft 

ci 

© 

02 

O 

ft 

H 


w 

H 

O 

£ 


© 

© 

f- 

CO 


xi 

ft 
© 
XI 
02 
• pH 
p-H 

X 

3 

ft 


oj 

ft 


O 

O 

•9 

« 

w 

ft 


ft 

> ~ H 
© 
ft 
c£ 

• pH 

X 

ft 



















500 


SUPPLEMENT. 




11. Ask him the name of the test-skein, or any other 
skein, and register it. 

12. Put down whether his selection was prompt or hesi¬ 
tating. 

13. Finally, as a control upon the test and as a substi¬ 
tute for the second and third color-test of the stick system, 
there have been added, especially for the surgical expert, 
two more large test-skeins, one, C, yellow, and the other, 
D, blue. The test C is exposed, and you may ask the man to 
match it if possible by the skeins from 1 to 20. If normal 
in color-sense, he will decline, or at the most only take the 
yellow-green skein, but if color-blind he will select a num¬ 
ber of the green skeins, which should be recorded. Then 
use test D, the blue skein, and let him match it from skeins 
21 to 40. If normal or green-blind, he will select blues 
only, but if red-blind he will pick out a series of roses, 
which should be recorded. 

In 1897 it was estimated that seventy-eight corporations, 
controlling 106,395 miles, have adopted the entire system. 

In 1900 reports show that one hundred and eleven 
corporations, controlling 149,151 miles, have adopted it. 

The Lantern.—Inasmuch as for two-fifths of his time, 
during the night an employe must govern his actions by 
colored signal lights, I have now to propose a lantern 
which is to be used by or under the orders of the Division 
Superintendent in addition to the wool-tests, and which 
contains those signals universally used on railroads, and 
additional glasses to imitate the changes induced by rain, 
smoke, fog, or snow. It consists of a lamp upon which can 
be placed an asbestos chimney having two disks, 4 in. or 10 
centimeters in diameter, so arranged that thin glasses, 10 
mm. in diameter, can be superimposed. This can be also 
placed over an Argand burner or other gas light, or an 
electric light can be employed to avoid heat, or a standard 
candle with a spring stick. The upper disk contains four 




EXAMINATION OF RAILWAY EMPLOYES. 501 


openings: one, two, five, and ten millimeters each, one 
white ground glass, one London smoke dark, one Lon¬ 
don smoke medium, one light pink, one light green, one 
cobalt. 

The lower disk contains the red, green, white, and blue 
colors in general use. By combining these with the ground 
or London smoke glasses of upper disk, atmospheric con¬ 
ditions can be imitated. The red placed over the cobalt 
gives a very deep red color; the green and cobalt imitate 
the blue green so much in use. To the color-blind cobalt 
appears as blue with no red or violet, and when combined 
with the blue of the lower disk appears of a bright red, but 
is called blue by the color-blind, blind to red. 

The effects of distance and size are produced by the 
openings from 1 to 10 mm. in the upper disk. Normal 
color-sense is known by the power to recognize the signals 
at 5 meters through the 1 mm. opening. If with the large 
one a man fails to see the signal at 5 meters or 16 feet, 
the color-sense is reduced to ; and a man placed at one 
meter, still failing, shows a color-sense =to and at 20" 
or | a meter, = 100 only. I have endeavored to provide 
“ confusion colors ” for both red and green and white in the 
three glasses in the upper disk mentioned as light red or 
pink, light green, and grey, or light smoke. Color-blind 
persons see these as one color, white or grey, and so call 

them. 

The test should be made in a dark room ; the various 
lights should be brought to view by rotating the disks, and 
the man be directed to call out the colors of the signals. 
The failures or successes should be recorded on a blank. 
No man should be accepted who would call the led signal 
green, or white; the green one red or white; or the white 
one red or green. The blue is always seen by the color¬ 
blind, and called properly. 

Not only congenital color-blindness but that central de- 


502 


SUPPLEMENT. 


feet caused by alcohol, tobacco, or other drugs, or diseases, 
is quickly detected. 

The disks may be called upper aud lower. The lower is 
for the “ direct,” the upper for the “ cross ” examination. 


Fig. 183. 



Thomson’s lamp. 

The lower contains ten glasses, designated by the num¬ 
bers from 1 to 10. Commencing with the white ground 
and going to the next green, then to red, etc., the tenth 
being the blue. These are the signals in use on all roads, 
and they should be named at once by a man with color- 
sense normal placed at 5 meters, in a darkened room with 
















































































































































































































EXAM IN A TION OF RAILWAY EMPLOYES. 503 


the small opening. The color-blind man may call white 
correctly, and he always does see blue, hence he has few 
chances of detection since he does see the green and red 
lights, and tries to tell them not by their color, but by their 
intensity. It becomes requisite to present them to his view 
in various conditions. Should he make no mistakes in his 
first testing with the lower disk, the openings from 10 mm. 
to 1 mm. in the upper should be brought into combination, 
decreasing the apparent size of the light and its intensity, 
and testing his color power as is done by test-letters. The 
normal eye should recognize the color through 1 mm, open¬ 
ing at 5 meters. 

The upper disk also has ten openings: 1 mm. known as 
A. 2. B. 5. C. 10. D. Ground white, E. London- 
smoke dark, F. Light London-smoke, G. Light pink, H. 
Light green, I. Cobalt, K. 

The ground white may be used as a means of making 
all glasses of the lower disk more solid in color; the dark 
London-smoke combined with them imitates the effect of 
fog, rain, or snow; or it may so change the intensity of a 
red as to cause the color-blind to call the same red either 
green or red. The light pink, a compound of red and 
blue, the light green, and the light London-smoke, are 
“ confusion colors ” and appear to the color-blind alike, 
and are called white. This is an attempt to imitate the 
“ confusion colors ” of the wool-tests for the first time, and it 
requires nice adjustment of the source of light. With the 
pink, the red-blind man sees no red, and the blue which he 
does see is changed by the yellow of the light within the 
chimney into his white; the green-blind man, in like man¬ 
ner, failing to see the light green, calls that and the grey- 
white, alike white. The ground glass of the lower disk 
should be used with these. 

The cobalt gives a red and blue light normally, but the 
color-blind see it only as blue. It has a value also in 


504 


SUPPLEMENT. 


causing the red of the lower disk to be very pure and dark 
so that a color-blind man may call the same red, with or 
without the cobalt, either red or green. The cobalt with 
the pure greens, gives the blue-green color adopted by 
many roads. Cobalt combined with blue gives a rose 
which is called blue by the color-blind. The man should 
be asked to tell what the lights indicate as signals. They 
mean white, safety; green, caution, run slowly; red, halt, 
danger; blue, inspector’s light, a train or car so guarded 
must not be moved. 

The numbers and letters used on the disks are too 
small to aid those defective in the testing. Any intelligent, 
not color-blind, examiner can use this color-tester, and 
report on the present blank the results, naming the mis¬ 
takes that have been made. The man’s quantitative color- 
sense may be found and stated. He should be placed at 16 
feet or 5 meters from the lantern, the smallest 1 mm. 
opening being used. This is sufficient for a normal eye. 
He may fail, and may when told to name the color call 
red green ; white, green ; or green, red. The openings are 
then increased to the largest, 10 mm., and failing again he 
has less than ^ of color-sense. He is then directed to 
approach the light to 1 meter, failing here he has -fo, and 
finally he shows y-Jy- only of color-sense, when he fails at i 
a meter or 20 inches away. 

A most interesting experiment can be made by placing 
the chimney over a lamp having some common salt mixed 
with the alcohol in it. The flame gives a monochromatic 
light, which renders all the colors alike to the observer with 
the normal color sense, and enables him to comprehend 
the defect of the color-blind. The color-stick seen with 
this yellow light in a dark room loses all its colored tints 
and becomes grey to the normal eye, and should be ex¬ 
hibited to the examinees by the surgical expert. 

The first man tested with the lantern failed on every 



EXAMINATION OF RAILWAY EMPLOYES . 505 


color but the blue. Called red green, but never recognized 
green. His acuteness was £ Rt. and Lt. Called cobalt 
blue; called light pink or red green, and London-smoke 
white. New wool-test: Shown rose called it blue, and 
selects all the blues, saying the other pinks are shades of 
green. With spectroscope: Has but two colors, blue and 
yellow, each shading to black with a light dirty white place 
where yellow and blue mingle. Stick : Calls red test-skein 
red, but picks confusion colors. 

Green : Calls it green, selects some light green skeins, then 
more greys, leaving best greens behind. 

Rose: Calls it red, then green, and matches it with fine 
grays. Calls white three squares of color on white paper 
composed of light pink, light green, and light gray. Finally 
calls two test glasses II inches in diameter, by day, held 
one foot away, both red, one being red the other green. 
Typical green blind. 

It may be of service to present to the ophthalmic experts 
in charge of the examinations of the various railroads the 
means that I have adopted for my own guidance in giving 
my final decisions. From the numerous methods described 
by scientific authorities I have selected ten that are prac¬ 
tical, simple, and especially fitted for the detection of color- 
defects in employes of railroads. A book of record should 
be kept in which each case, with the results of the testing, 
should be entered. The Pennsylvania Railroad system 
provides that the preliminary examination should be made 
under the direction of the Division Superintendent by non¬ 
professional examiners, but it is to be under the supervision 
of one professional competent surgeon, who is known as the 
surgical expert, or ophthalmic surgeon, who becomes re¬ 
sponsible for the qualities of the tests, and who gives the 
final decision in all cases referred to him. Thus the men 
are protected from the errors of lay examiners, and do not 
lose their places until pronounced defecti ve by professional 


506 


SUPPLEMENT. 


authority. With ordinary care no color-blind man should 
escape detection by the lay examiner, but men really fit 
for the service might be unfairly treated. 

The most important duty of the surgical expert is to 
explain the entire system to the Division Superintendents 
and to instruct their examiners. 

When referred to the expert the man found color-blind 
will present himself with the blank of his examination, and 
the surgical expert will then corroborate this by the follow¬ 
ing means : 

1. The color-stick or the new wool test or both. 

2. Holmgren’s set of one hundred of fifty various-colored 
skeins will be used and the proportion of mistakes recorded. 

Its main value is to preserve the record, especially of 
those cases of partial color-blindness so difficult to decide. 
Let the man assort these skeins at his pleasure, placing 
them in various piles. He generally concludes with a red, 
blue, green, yellow, neutral, and grey pile. A small 
piece clipped from each skein makes a valuable record 
when placed in an envelope, and marked with the name 
given, and teaches much to the examiners. 

3. Browning’s pocket spectroscope will then be used, and 
the man be directed to describe the colors he sees when look¬ 
ing through the instrument. If color-blind he will say that 
he sees but two colors, yellow and blue, with a gray or a 
neutral band between them. 

4. The color-tables of Stilling will then be used; these 
are so arranged that on a colored background letters and 
figures are printed in the confusion colors of this back¬ 
ground so as to be indistinguishable by the color-blind. 

It now becomes requisite to test the central vision to de¬ 
tect amblyopia, whether toxic from tobacco, alcohol, drugs, 
etc., or caused by disease, heredity, or accident, as well as 
to determine the power to perceive the signal-colors that 
are used by night. 


EXAMINATION OF RAILWAY EMPLOYES. 507 

In the color-blindness of tobacco, alcohol, drugs, etc., 
the center of the field of vision only is rendered ambly- 
opic, hence the skeins tail to detect it, they being properly 
seen by the peripheral parts of the retina. It may be 
suspected by the loss ot acuity with the testdetters. Since 
it is confined to the macular region only the color-test 
must be small. In a case of tobacco amblyopia, in the 
absence of a perimeter, I used recently the 5 of hearts 
held about one foot from the face. The patient saw 
the four outer hearts red, the center one black, and later 
on red after treatment by strychnine. The three of the 
same suit answers well to detect the defect, held hori¬ 
zontally. W ith one eye closed, the right for example, fixed 
on the center heart, the one to the right disappears, or is 
degraded in tone; looking with left eye the heart to the 
left is lost or changed in tone. 

A red Maddox rod demonstrated an entire scotoma in an¬ 
other recent case, the red line being broken for a space in 
its centre, to be seen later as a white portion, and finally 
as a full red streak as the case recovered under treatment. 
These tests demand good faith from the patient, but they 
show the inability of a man with toxic amblyopia to see 
the signals used by night. 

The color defect generally affects a portion of the centre 
of the field equal to the diameter of a test-glass held at 
one foot from the eye = one and a half inches, or about 6°. 

5. A piece of dark cobalt-blue glass should be used in 
the trial-frame over each eye separately, and the man be 
directed to look at the flame of a candle or other small 
light, from a distance of twenty feet. An eye normal in 
refraction and color-sense sees the light colored rose or 
pink, surrounded by a blue halo. To a hypermetrope there 
may be a blue light, with a ruby-colored ring or halo; but 
two colors will always be seen, while the color-blind man 
sees but one color, blue, or a light spot with a blue halo. 


508 


SUPPLEMENT. 


6. Thomson’s lantern has already been described and 
takes the place of Bonders’ instrument. 

7. A tin lantern, with a switch-light condenser having 
a four-inch opening arranged so as to admit of placing 
pieces of white (ground), green, red, blue, and London- 
smoke glass before it, is now employed. This could also be 
made to take the place of Donders’ instrument, if covered 
with a front, and with a sliding-piece with small perfora¬ 
tions. A man failing to recognize the light from a four- 
inch aperture leaves no possible room for doubt, and this 
fixture is useful in convincing the friends of the man, and 
any railroad officers who may desire a rude test. The light 
is in diameter 100 mm., and should be seen at 500 metres. 

8. The instrument of Mr. Carter, of London, is then 
made use of. This is to guard the surgical expert against 
a hasty opinion, and is to act as a check upon all -wool 
tests. It is based upon the sensibility of the retina and its 
power to recognize form and color in various intensities of 
light. The surgeon and the man examined regard the 
tests simultaneously while the quantity of light is varied; 
thus, possible errors with other tests, especially Holmgren’s, 
can be avoided. 

9. In Br. Chibret’s instrument, by means of polarized 
light various colors may be produced at will. The color¬ 
blind betray themselves by placing the instrument so that 
two dissimilar disks of light appear to them alike. 

10. Finally, an assortment of flags that have been in 
actual use new, worn and old, ten of each color, white, 
green, blue, and red are used as a test. These are thrown 
down in a confused mass on the floor, and the man is 
directed to properly assort them, and to tell their color at 
a distance of twenty feet. Astounding mistakes are often 
made; as, for example, when a man is directed to take a 
red flag and use it to protect the rear of a train, he may 
select a green one. Of two reds he may call one green. 


EXAMINATION OF RAILWAY EMPLOYES. 509 


A profound understanding of this curious defect of color- 
perception must be acquired to enable the surgical expert 
to make the best use of these various methods, and while 
they are sufficient, they are decisive and require but little 
time. Perhaps the transcript of one case from my record- 
book may illustrate these brief descriptions: 

J. H., employed by the Pennsylvania Railroad Com¬ 
pany, forty-three years old ; found defective and referred 
for final opinion. 

Color-stick: With green, selects Nos. 1, 2, 3, 4, 6, 7, 11, 
13, 15, 17 ; with rose, selects Nos. 22, 25, 21, 27, 28 ; with 
red, selects Nos. 31, 32, 33, 34, 37. 

Holmgren: Green, selects 2 greens and 21 confusions; 
rose, selects 5 greens, with 13 confusions; red, selects 8 
greens, with 9 confusions, 2 greens. 

Donders: Fails at 5 m. on all apertures; fails at 1 m. 
on all apertures; $ m. on all apertures. 

Calls, with 20 mm. opening, green red; red green and 
w T hite, light red. 

He made more mistakes than successes, with gray (Lon- 
don-smoke glass) over white; called it red and green, as 
light was increased or diminished, and finally declared that 
he had never seen such lights on a railroad. 

Failed with switch-light, 4 inches in diameter, at 5 m. 
and at 1 m., and manifested a color-blindness or defect 
greater than as he failed to see at 1 m. what a normal 
eye would recognize infallibly at 500 metres. 

Cobalt-glass : Sees white light with blue halo ; no red or 
rose. 

Flags: At 1 m. calls dirty-white green ; fails to distin¬ 
guish red from green. He was then told to select from a 
pile of flags the danger-signal, or red one, and to hurry 
back and protect his train; with his own hands and delib¬ 
erately he chose six—three red, two green, and one blue- 
stating that “ they would all stop trains.” 


510 


SUPPLEMENT. 


Stilling’s tables: Fails in all but VII., which should be 
recognized by a color-blind. 

Pronounced color-blind and unfit for any duty in which 
he would govern his actions with color-signals. 

I will conclude by a regret that space does not permit a 
full treatment of more than this system which seems to 
have gained the confidence of railroad officers, as is proved 
by its adoption for the protection of 150,000 miles of 
track. Its chief originality and merit seems to be the 
placing of the responsibility on the Division Superintend¬ 
ent, who can know the men on his division, and can in¬ 
crease or diminish his force without the delay of medical 
examinations. The system of odd and even numbers of 
the wool-tests enables him to supervise at a glance the 
work of his assistants, who make and record the exami¬ 
nations. He needs to know only that men reach a certain 
degree of standard in sight, hearing, and color sense. There 
are now 78,000 men employed on the Pennsylvania railroad, 
all of whom whose duties demand a high standard have been 
properly tested. The system acts as a quarantine to pre¬ 
vent admission of defective men into the service. 

It is understood that in youth hypermetropic men may 
gain entrance, but as they reach middle life, the examination 
for promotion, if they are valuable men, indicates their 
defect, and they are expected to use glasses to restore nor¬ 
mal vision. Re-examinations at stated periods are strongly 
advised. The standard of vision is not changed. A paper 
of Dr. A. G. Thomson in the appendix of De Schweinitz and 
Randall’s text-book, on acuity of vision requisite, and used 
here and abroad, may be consulted. 

The New Wool-test introduced in 1894 is an improve¬ 
ment upon, but does not displace the stick. 

The revolving test-letters prevents them from becoming 
too familiar. 

The lantern now added to the wool-tests will cover the 


EXAMINATION OF RAILWAY EMPLOYES. 511 


two-fifths of the employes’ time spent in seeing signals by 
night; makes the examination of color-sense complete, and 
detects the central blindness of disease or abuse of tobacco 
and alcohol. 

Like Dr. Allport’s method of examination of school-chil¬ 
dren by their teachers, it makes those defective known, ex¬ 
cludes them from the service, or enables the ophthalmic sur¬ 
geon to use his skill in relieving them. Perhaps in the future 
the examinations may all be made by skillful surgeons, 
but the system has done much good, and has induced one 
hundred and eleven great corporations to adopt some 
method of control over 150,000 miles of track, and is now 
rendered more complete than ever before. 

The tests here described can be obtained of Queen & 
Co., of Philadelphia, and with each one will be sent a cer¬ 
tificate of its accuracy signed by Dr. Thomson. 




APPENDIX. 


FORMULAE, ETC. 

Nitrate of Silver. 

1. Mitigated Solid Nitrate of Silver (B. P. 1885): 

Nitrate of Silver 1, 

Nitrate of Potash 2. 

Fused together and run into moulds to form short, pointed sticks. 

Used for granular lids and purulent ophthalmia. 

The strength above given is known as No. 1, and is that which I 
generally use; three weaker forms are made, known as Nos. 2, 3, 
and 4, containing respectively 3, 31, and 4 parts of nitrate of potash 
to 1 of nitrate of silver 

Pure nitrate of silver is never to be used to the conjunctiva. 

2. Solutions of Nitrate of Silver : 

(1) Nitrate of Silver gr. x or xx, 

Distilled Water 3j. 

Used by the surgeon for purulent ophthalmia, granular lids, and 
chronic conjunctivitis, and some cases of ulcer of the cornea. 

3. (2) Nitrate of Silver gr. j or ij, 

Distilled Water 5j. 

Used by the patient in various forms of ophthalmia, only a few 
drops to be used at a time, and not more than three times a day. 

All solutions of nitrate of silver should be kept in glass-stoppered 
bottles; any trace of organic matter decomposes the salt, and a black 
deposit of metallic silver falls to the bottom; the action of light 
favors this decomposition: amber-tinted glass is said to counteract 
the chemical action of light. Dark blue bottles should not be used, 
as they only hide the deposit of reduced silver. 

33 


( 513 ) 



514 


APPENDIX. 


Sulphate of Copper. 

4. A crystal of Pure Sulphate of Copper , smoothly pointed, may 
be used for touching granular lids of old standing. 

5. Lapis Divinus: 

Sulphate of Copper 1, 

Alum 1, 

Nitrate of Potash 1. 

Fused together, and camphor equal to of the whole added. 
The preparation is run into moulds to form sticks. It should be 
kept in a stoppered bottle. 

Largely used for the treatment of chronic granular lids. 

6. Solutions of Sulphate of Copper or of Lapis Divinus gr. j 
in 5 j of distilled water, are also very useful for many forms of 
chronic conjunctivitis. 

Lead Lotion : 

7. Liquor Plumbi Subacetatis (B. P.) ^j, 
Distilled Water Oj. 

(1 in 160.) 

Used in chronic conjunctivitis when the cornea is sound, and in 
inflammation of the eyelids and lachrymal sac. 

Spirit Lotion : 

8. Rectified (or Methylated) Spirit if iv, 

W ater ^ xvj. 

Used as an evaporatiug lotion to allay or prevent inflammation of 
the wound after operations on the eyelids. 

9. Lead and Spirit Lot ion : 

Spirit Lotion Oj, 

Liquor Plumbi Subacetatis (B. P.) ^ij. 

Used in the same cases when there is no fear that the cornea is 
abraded or ulcerated. A better antiphlogistic than spirit alone. 

Mercury. 

10. Weak Solutions of Perchloride of Mercury are extensively 
used for cleansing the conjunctiva, eyelids, etc., before, during, and 
after operations. A solution of 1 grain in 6000 of water (common 
or distilled > (=gr. j in fl. if xij ) may be freely used for the above 
purposes, and a stronger one (1 to 2500) ( = gr. j in fl. 3vj) as a 


APPENDIX. 


515 


lotion for catarrhal ophthalmia, etc. Some surgeons use much 
stronger solutions. The Moorfields Pharmacopoeia has a lotion 
containing 1 grain in fl. 3 viij, or 1 in 3500. 

11. Solutions of Perchloride of Mercury in glycerine and dis¬ 
tilled water of the strength of 2 or 4 per cent, have been introduced 
for the conjunctiva in cases of trachoma, either alone or after ex¬ 
pression of the follicles; perchloride of this strength has also been 
used for some cases of ulcer of the cornea. 

Sulphate of Zinc: 

12. Sulphate of Zinc gr. j or ij, 

Water or Rose Water 3 j. 

Chloride of Zinc : 

13. Chloride of Zinc gr. ij, 

Water 3 j. 

If there is a deposit, add of dilute hydrochloric acid just enough 
to make a clear solution. 

14. Chloride of Zinc Paste ( Caustic) : 

The exact composition of this paste varies in different hospitals ; 
the followiug is the formula in use at Moorfields : 

Chloride of Zinc 480 grains, 

Wheat Flour 180 grains, 

Water, or Liquor Opii Sedativus, fl. ^j. 

Alum : 

15. A stick of pure crystalline alum forms a very useful appli¬ 
cation for mild or long-standing cases of granular conjunctiva, and 
for many forms of chronic palpebral conjunctivitis. It may be used 
by the patient himself without the slightest risk. 

16 . Lotion: 

Alum gr. iv to gr. x, 

Water £j. 

The above lotions are in common use in the milder forms of acute 
and chronic ophthalmia. The chloride of zinc occasionally irri¬ 
tates; it is specially used in purulent and severe catarrhal ophthal¬ 
mia instead of the weak nitrate of silver lotions. The stronger 
alum lotion is often used in the same cases. The alum and sul¬ 
phate of zinc lotions may be used unsparingly to the conjunctiva; 
the chloride, even in severe cases, not more than six times a day. 


516 


APPENDIX . 


Boric Acid Lotion : 

17. Boric Acid 4. 

Water 100 by weight. 

Used as an antiseptic before and after operations on the eyeball, 
and in the treatment of conjunctivitis and of suppurating ulcers of 
the cornea. 

Boric acid in very fine powder may be used for dusting on to 
the cornea in cases of severe suppurating ulcer; it causes scarcely 
any pain, and may be applied as often as three times a day (p 139). 
The crystals are difficult to powder finely, but an almost impalpable 
amorphous powder, obtained by preventing regular crystallization, 
can be had. 

Mr. Martindale has made for me some soluble styles containing 
about 60 per cent, of boric acid for use in cases of lachrymal obstruc¬ 
tion with much secretion of mucus (p 102 ). 

Solutions of boric acid often tarnish steel; instruments should 
therefore not be left in them. 

Carbonate of Soda : 

18. Carbonate of Soda gr. x, 

Water 3 j. 

Used for softening the crusts in severe ophthalmia tarsi. A small 
quantity of the lotion, diluted with its own bulk of hot water, to be 
used for soaking the edges of the eyelids for ten or fifteen minutes 
night and morning. 

Tar and Soda : 

19. Carbonate of Soda £jss, 

Liquor Carbonis Detergens sjj to Jss, 

Water to Oj. 

Used in the same cases as the last. 

Borax: 

20 Biborate of Soda gr. x to xx. 

Water ^j. 

Used in the same cases as the last 
Quinine Lotion: 

21. Sulphate of Quinine gr. iij, 

Acid. Sulph. dil. ^B. P.) just enough to dissolve, 
Water 3 j. 

Used in diphtheritic ophthalmia. 


APPENDIX. 


517 


Carbolic Acid Lotion: 

22. Absolute Phenol 5, 

Water by weight 100. 

Used in puruleDt ophthalmia. It is important to use absolutely 
pure carbolic acid for the conjunctiva. Severe irritation often 
follows if any other varieties are employed. 

23. Pure carbolic acid is useful as an application by the surgeon 
himself to the surface of infective or obstinate ulcers of the cornea. 

Lotion of salicylic acid is so irritating to the surface of the eye 
that it can seldom be used. The same objection applies to salicylic 
wool used for dressing the eye after operation. 

24. Calomel Powder: 

Used for dusting on the cornea in some cases of ulceration. It is 
flicked into the eye from a dry camel-hair brush. 

25. Yellow Oxide of Mercury ( Yellow Ointment; Pagenstecher’s 

Ointment ): 

Yellow Oxide of Mercury gr. xxiv, 

Vaseline z i 

(1 in 20.) 

26. Weaker preparations, containing gr. viij or less of the 
yellow oxide to 3j (1 in 60 or less), are often better borne. 

Used in many cases of corneal ulceration and recent corneal 
nebulae, a morsel as large as a hemp-seed being inserted within the 
lower lid by means of a small brush, once or twice a day. It is also 
suitable for ophthalmia tarsi. 

In some of the Continental eye hospitals, where it is the custom 
for this remedy, among others, to be applied by the surgeon him 
self, stronger preparations are used. 

27. Yellow Ointment with Atropine : 

Yellow Oxide of Mercury gr. viij or less, 
Atropine gr. 

Vaseline £j. 

Use in the same way as 25 and 26. 

28. Red Oxide of Mercury : 

Ked Oxide of Mercury gr. xxiv or less, 
Vaseline £j. 

Used for ophthalmia tarsi, etc. Was formerly used for corneal 
ulcers and nebulae; but the yellow oxide, which being made by 


518 


APPENDIX. 


precipitation is not crystalline, is now generally preferred because 
less irritating. 1 

29. Nitrate of Mercury (Citrine Ointment): 

Unguentum Hydrargyri Nitratis (B.P.) gj, 
Vaseline or Prepared Lard gvij. 

Used in the same cases as 28. 

30. Iodoform: 

Iodoform may be used’either in substance, or as an ointment made 
with vaseline. 

Iodoform gr. x to gr. xxx or more, 

Vaseline £j. 

Ung. Iodoformi (B.P. 1885): 

Iodoform gr. xlviij, 

Benzoated Lard ^j. 

30a. Iodol, which is odorless, may be used in the same way. 
The precipitated iodoform (impalpable powder) should be used in 
preference to the ordinary, or crystalline, form for the eye. 

Boric Acid Ointment (B P. 1885): 

31. Boric Acid gr. lxviij to ^j of Paraffin. 

32 Cocaine. 

Cocaine was brought into clinical use in September, 1884, at Vienna 
and in London and elsewhere early in October. 

A 2 per cent, solution of a salt of cocaine dropped into the con¬ 
junctival sae causes smarting for about half a minute, followed by 
numbness, rising to complete anesthesia of ocular conjunctiva and 
cornea in about two to five minutes ; in three to five minutes after 
the maximum is reached, feeling begins to return, but slight numb¬ 
ness continues for about twenty minutes. There is often a feeling 
of coldness as sensation is returning. Cocaine also causes widening 
of the palpebral fissure by retraction of the upper and lower lids, 
whitening of eyeball from contraction of bloodvessels, mydriasis, 
very slight weakness of Acc., and perhaps lowering of the eye 
tension. These effects last about half an hour, except the mydriasis, 
which remains in some degree about twenty-four hours. The pupil 
dilated by cocaine remains active to light and Acc.; if atropine be 

1 The ointnent known as “ Singleton’s Golden Eye Ointment ” appears to 
contain the crystalline red oxide in fine powder as its active ingredient. A 
sample kindly analyzed for me by Mr. S. Plowman, contained 70 grains of 
the oxide to the ounce. 


APPENDIX. 


519 


added the pupil becomes larger than from either drug singly. 
Eserine quickly and fully overcomes the effect of cocaine. Acc. is 
completely paralyzed for a very short time if cocaine be used every 
few minutes for about an hour. These effects of cocaine (except the 
last) are explicable on the supposition that it causes spasm of the 
sympathetic nerve-fibres to the eyelids, iris, and superficial blood¬ 
vessels; whether a similar contraction of the arteries of the ciliary 
muscle, brought about by the repeated use of the drug, explains the 
fleeting paralysis of Acc. is open to question. Cocaine has no ascer¬ 
tainable action on the vessels of the retina and choroid. Cocaine is 
thought by some to aid the action of eserine in chronic glaucoma, 
when the two are used together; this is intelligible if cocaine acts by 
contracting the ciliary arteries. 

In ophthalmology cocaine is used chiefly for anaesthesia before 
operations on the eyeball, and painful applications to the palpebral 
conjunctiva. For the former, a freshly made 2 per cent, solution 
of perfectly pure hydrochlorate of cocaine in freshly boiled distilled 
water is the safest preparation ; but gelatine disks of the pure salt, 
if free from hygroscopic tendency, may be safely used. Solutions 
in oil or vaseline are uncleanly and not suitable for surgical purposes. 
Watery solutions of cocaine should be used quite fresh ; even if made 
with boric acid or camphor water they often, if kept, grow fungi, 
and are then unsafe. Cocaine if too freely used causes dryness, 
loosening, and even separation of the corneal epithelium ; the desic¬ 
cation of the corneal epithelium is said to occur in direct proportion 
to the frequency of use of the cocaine, and of exposure of the cornea 
to the air, rather than to the strength of the solution employed. 
Not more than three applications need be made, within five minutes, 
before operations for cataract, etc. Cocaine has been accused of pro- 
ducing glaucoma, but, as far as the few recorded cases show, without 
much reason. For deadening granular lids, or similar conditions, 
a much stronger solution must be painted over the affected surface 
(I use a 20 per cent, solution or the solid salt). For small tumors 
about the lid, etc., a 1 or 2 per cent, solution is injected in different 
directions at the base of the growth. 

If the eye be congested or inflamed cocaine acts much less perfectly 
on the conjunctiva; but it acts as well upon an ulcerated as upon a 
healthy cornea. As the cocaine takes effect only on the part which 
it touches, the solution must be made to flow all over the cornea and 
conjunctiva; and as it penetrates little, if at all, it must be injected 
under the conjunctiva if we wish to render the later (tenotomy) 


520 


APPENDIX. 


stage of a squint operation painless, or to excise the eyeball under 
its influence. Cocaine as ordinarily used does not seem greatly to 
affect the sensibility of the iris ; injection into the anterior chamber 
for this purpose is not practicable even if safe. 

Cocaine is used in acute iritis in conj unction with atropine, with the 
idea that it will assist the anodyne and mydriatic effects of the latter. 
My own experience does not enable me to speak strongly on this 
point. 

Faintness and other signs of nervous depression have been reported 
as due to cocaine, even when used to the eye alone. I believe that 
these symptoms are generally due to reaction after the mental strain 
attending an operation of which the patient is conscious; for before 
cocaine was used we were familiar with the occurrence of faintness 
and vomiting from time to time when eye operations had been under¬ 
gone without antestliesia. 

Mydriatics and Myotics: 

33. ( 1 ) Strong Atropine Drops: 

Sulphate of Atropine gr. iv, 

Distilled Water jjj. 

Used in cases where the rapid and full local action of the drug is 
required. For many purposes atropine drops may be used consider¬ 
ably weaker than the above. Atropine (a single drop, of 2 grains 
to Jj, or about 0.5 per cent.) begins to dilate the pupil in about 
fifteen minutes, and to paralyze the accommodation a few minutes 
later; it produces wide dilatation of the pupil (8 to 9 mm.) in thirty 
to forty minutes, and full paralysis of accommodation in about two 
hours. Both remain at their height for twenty-four hours, and the 
effect does not pass off entirely till from three to seven days, the ac¬ 
commodation recovering rather sooner than the pupil. If stronger 
solutions be used several times, the action continues longer. The 
effects of atropine are only very temporarily and imperfectly over¬ 
come by eserine. Atropine slightly lowers the tension of the 
healthy eye, but usually increases the tension in glaucoma. 

( 2 ) Weak Atropine Drops: 

Sulphate of Atropine gr. £ to 
Distilled Water 5 j. 

Used when, for optical purposes, it is desired to keep the pupil 
dilated for a long time, as in immature nuclear cataract. A single 
drop about three times a week will generally suffice. Very weak 
atropine acts more on the pupil than on the accommodation. 


APPENDIX. 


521 


Solutions of sulphate of atropine keep for an indefinite time; 
the flocculent sediment which often forms does not impair their 
efficiency. The mydriatics and myotics may be used in the form of 
ointment with vaseline; a smaller percentage of the drug is then 
necessary, and toxic effects are less likely to follow; the alkaloids 
themselves must be used, their salts not being soluble in fats and 
oils. 

(3) Ung. Atropince: 

Atropine (Alkaloid) gr. iv, 

Pure Vaseline ^j. 

This ointment is needlessly strong for most purposes; 1 grain to 1 
ounce is usually enough. 

(4) Lamella Atropina (B P. 1885) gr. in each. 

34. Scopolamine: 

Scopolamine Hydrobromate gr. | to gr. 1. 

Pure Vaseline ^j. 

This is a powerful mydriatic, and may be used where atropine is 
not tolerated; it is more powerful than the latter, and does not pro¬ 
duce local irritation so readily. 

35. Tropacocaine. —A 3 per cent solution in normal saline solu¬ 
tion is used for anaesthesia of the cornea; its effect begins more rap¬ 
idly and lasts longer than that of cocaine, and it said to be less toxic ; 
it does not produce mydriasis as a rule. 

36. Daturine: 

Sulphate of Daturine gr. iv, 

Distilled Water ^j. 

Used as a mydriatic in cases where atropine causes conjunctival 
irritation. 

37. Duboisine: 

Sulphate of Duboisine gr. j, 

Distilled Water 5 j. 

A mydriatic, acting more quickly and powerfully, and passing off 
in a shorter time, than atropine. It is tolerated in cases where 
atropine causes conjunctivitis. To be used with caution, as well- 
marked toxic symptoms are sometimes caused. 

Duboisine begins to act on the pupil and accommodation in less 
than ten minutes, produces full mydriasis in less than twenty min¬ 
utes, and complete cycloplegia in about one hour The maximum 
effect does not last quite so long as, and the effect passes off com¬ 
pletely rather sooner than, that of atropine. Duboisine seldom breaks 


522 


APPENDIX. 


down iritic adhesions which have already resisted atropine. Its chief 
use seems to be for cases in which atropine causes irritation. 

38. Holocaine has been employed of late in 1-per-cent, solution 
as a substitute for cocaine. It possesses the advantage of not enlarg¬ 
ing the pupil nor of affecting the ciliary muscle, and lias decided 
bactericidal properties. 

39. Eucain hydrochlorate , in a 2-per-cent, solution, is an active 
local anaesthetic, but possesses the disadvantage of exciting a sharp? 
stinging sensation, which persists for some minutes after its instilla¬ 
tion. 

40. Ilomatropine: 

Hydrobromate of Homatropine gr. iv, 

Distilled water ^j. 

A mydriatic, acting rather more quickly and passing off much 
sooner than atropine; very convenient, therefore, for dilating the 
pupil for ophthalmocopic examination. 

Homatropine begins to act on the pupil and accommodation in 
from five to fifteen minutes; the greatest dilatation of pupil (usually, 
however, rather less than that obtained by atropine) is reached in 
about fifty minutes, and complete or nearly complete cycloplegia in 
an hour or rather less (with the solution of gr. iv to ). The full 
effect is only maintained, however, for an hour, more or less, and 
both pupil and accommodation usually recover completely in twenty- 
four hours or less. Its action is quicker and rather more powerful 
if it be used with cocain, 2 per cent, of each in distilled water. 

Homatropine Hydrobromate 1 , 

Distilled Water 40. 

A solution of this strength is much used to produce paralysis of 
the accommodation for the measurement of refraction. A drop 
should be distilled every five minutes until 4 or 5 drops have been 
applied, and the refraction measured at the end of one hour.] 

For producing rapid but brief paralysis of Acc. (in ametropia) a 
solution containing 2 per cent, of cocaine and 2 per cent, of homatro¬ 
pine is recommended by Mr. Lang, and is convenient in suitable 
cases; the maximum effect is gained in from twenty to sixty min¬ 
utes, but soon begins to decline. 

41. Eserine (Physostigmine) (Alkaloid of Calabar Bean): 

(1) Sulphate of Eserine, gr. iv 
Distilled Water, 5 ]. 


APPENDIX. 


523 


Used in mydriasis and paralysis of the accommodation, whether 
caused by atropine or by nerve lesions, in some forms of corneal 
ulcer, and in acute glaucoma. 

(2) A weaker solution (gr. j to 3 j) is often better 
borne. 

Eserine begins to contract the pupil and cause spasm of the ac¬ 
commodation in about five minutes; its maximum effect is reached 
in twenty to forty-five minutes. Its full effect on the accommoda¬ 
tion lasts only an hour or two, but the pupil does not completely 
recover for many hours, sometimes two or three days. A very weak 
solution acts more on the pupil than on the accommodation. Ese¬ 
rine causes pain in the eye and head, arterial ciliary congestion, and 
twitching of the orbicularis; the pain, sometimes severe, seldom lasts 
long. Eserine lessens the tension in primary glaucoma; its effect is 
increased in this disease if used with cocaine, on account of the con¬ 
traction of the ciliary arteries brought about by the latter. 

(3) Lamellce Physostigmince (B. P. 1885) gr. xoVo i n eac h. 

All the mydriatics and myotics may be obtained in the form of 
small gelatine disks of known strength (made by Savory and Moore, 
and by Martindale), which are sometimes more convenient than the 
solutions. Of the mydriatics, homatropine, scopolamine, and duboi¬ 
sine are much the most expensive. 

42. Belladonna Fomentations: 

Extract of Belladonna 3 j to 3 ij, 

Water Oj. 

Warmed in a cup or small basin and used as a hot fomentation in 
suppurating and serpiginous ulcers of cornea. 

43. Pilocarpine for Subcutaneous Injections: 

Hy dry chlorate of Pilocarpine gr v, 

Distilled Water £j. 

Dose, TTtiij, gradually increased, to be injected daily or less often. 
Used in cases of retinal detachment, choroiditis, and retinitis. 

44. Pilocarpine Drops , gr. iv to 5 J*. 

Pilocarpine is a myotic like eserine, but its action is much 
weaker. 

45. Fluorescine for staining the cornea. 

Fluorescine 2 per cent., 

Bicarbonate of Soda 3 per cent., in distilled water. 

A drop placed between the lids will stain the cornea where its 


524 


APPENDIX. 


covering epithelium is imperfect. A drop of cocaine used after the 
fluorescine precipitates it and makes the staining more obvious. 

46. Jequirity” seeds, obtained from a leguminous plant, are 
used in South America for the cure of granular lids (p. 120). They 
can now be readily obtained in moderately fine powder. The infu¬ 
sion is made by soaking the powder in cold water for a couple of 
hours, or better in water at 120° F., allowing it to stand till cool, 
and straining through muslin; it is then ready for use, but will re¬ 
main active for several days. When obviously decomposed (foetid) 
it is no longer active. The simple powder dusted into the con¬ 
junctiva is said to be active, but two or three trials which I made 
with it were negative. 

The action of jequirity probably depends upon a nitrogenous 
ferment, not as was for a time believed upon a specific microbe. A 
substance possessing the peculiar properties of the natural seed has 
been separated by more than one experimenter, but does not appear 
to be procurable in the market; it is difficult to make, and its com¬ 
position seems to vary. 

As the intensity of action of jequirity infusions of the same 
strength varies very much in different persons, and is sometimes 
very severe, it is best to use a weak preparation (1 grain of powder 
in 100 grains of water, or ^j to fl. ^ xijss) for all cases at first. A 
single prolonged application or several applications, within a few 
minutes to the everted lids will suffice. 

47. The infusion of extract of suprarenal capsules 
possesses marked vaso-constrictor properties, and is of great service 
in operations upon the ocular muscles in forestalling any hemor¬ 
rhage that might obstruct the field of operation. When applied 
locally for either therapeutic or operative purposes, it should always 
be preceded by a 5-per-cent, solution of cocaine, so as to secure the 
combined ansesthetic and enhanced effects of the cocaine and ex¬ 
tract. The astringent 'action of the extract begins in from thirty 
to forty seconds, and lasts from one-half to three hours. As the 
extract undergoes putrefactive changes very quickly, it should be 
freshly prepared. Vansant recommends the following solution : 5 
grains of the capsule, 11 grains of boric acid, and ^ ounce each of 
camphor and distilled water, then filter. 

48. Subconjunctival Injections. 

Injections beneath the conjunctiva of a solution of corrosive sub¬ 
limate or of normal salt solution have been practised during recent 


APPENDIX. 


525 


years by a number of eye surgeons, more particularly by French 
ophthalmologists. The method of procedure is as follows : After 
two preliminary instillations of a 2-per-cent, solution of cocaine 
into the conjunctival sac, ^ of a milligramme of corrosive subli¬ 
mate, with 5 milligrammes of cocaine hydrochlorate, is injected by 
means of a Pravaz syringe beneath the conjunctiva. The injection 
is followed by pain and by marked congestion and swelling of the 
conjunctiva, the latter symptom not usually disappearing until after 
several days. These injections have been employed in all forms of 
corneal ulceration, in scleritis, irido-cyclitis, and choroiditis and 
retinitis, but the results obtained from them are uncertain, except in 
progressive corneal ulcers, where they seem to exercise a marked 
beneficial action. 

49. Leeching. 

Blood may be withdrawn from the eye either by the application 
of one or more leeches to the temple, or by the use of an instrument 
named the artificial leech of Heurteloup. This apparatus consists 
of a sharp rotary drill for incising the skin, and a suction cupping- 
glass. If the natural leech be applied, it should be floated in water 
in a test-tube and brought in contact with the skin of the temple. 
Leeching is particularly serviceable in combating inflammations of 
the iris and of various deep-seated affections. 

50. Compresses. 

Heat and cold may be applied in either a moist or a dry form. A 
greater penetrating action is usually derived from the moist com¬ 
press, whether it be hot or cold ; and in addition it possesses the 
greater advantage of washing away all secretions from the conjunc¬ 
tival sac. 

The most effective manner of applying moist cold is by means of 
the ice compress. This is prepared as follows: Several pads of 
gauze of three or four thicknesses, about the size of a silver dollar, 
are laid on a block of ice. The ice should be suspended in a re¬ 
ceptacle with perforations in its bottom, which will permit the water 
and any secretion from the compress to drain into a jar beneath it. 
An ordinary kitchen cullender and wash-basin will answer very 
well for this apparatus. One of the pads is taken from the ice as 
soon as it has been saturated and is applied to the closed lids; it 
should be removed in a few moments and another one substituted for 
it. Compresses of absorbent cotton which have been soaked in 
ice-water may also be used; they should be squeezed out sufficiently 


526 


APPENDIX. 


to prevent any of the water trickling over the patient’s face and 
neck. Cold may also be applied by means of the ordinary douche, 
or by holding a small cake of ice directly to the eye; but these 
should be discarded for the compress, as they can only be used inter¬ 
mittently. 

Dry cold is usually applied by placing a bladder or a small ice- 
bag filled with cracked ice directly over the lids; or a similar effect 
may be gained by passing a cold stream through a coil of tubing 
which has been moulded to conform to the shape of the globe. Both 
of these methods have the objection of making more or less pressure 
upon a sensitive organ, of being less active than the moist form of 
application, and of not washing away the secretions. 

Moist Heat. Hot compresses consist in several thicknesses of 
gauze, which have been saturated in very hot water, and then 
applied to the eye as hot as they can be borne. The same effect may 
be gained by placing upon the eye little muslin bags filled with 
camomile flowers, which have been dipped in boiling water. The 
continuous application of moist heat is best accomplished by pre¬ 
paring a poultice of ground slippery-elm bark, or by bandaging a 
hot saturated compress of spongiopiline to the eye. 

Dry Heat. This is well applied either in the form of a hot-water 
bag or by packing a pad of heated flannel or absorbent wool into the 
hollow over the eye and holding it in place with a flannel bandage. 
These compresses should be as hot as the patient can bear, and care 
should be exercised that they do not make too much pressure on the 
globe. 

As the prolonged action of either heat or cold is likely to excoriate 
the skin of the lids, it is well to keep the region about the eye 
anointed with sweet oil or vaseline. It is also important to remem¬ 
ber that the intermittent action of both agents is injurious to the 
eye, so that the attendant should be charged that the compress be 
changed every few minutes during the time of application. 

51. Bandages for the eyes may be of thin flannel or soft calico. 
A linen or cotton bandage, about ten inches long, with four tails of 
tape, or a loop of tape embracing the back of the head (Liebreich’s 
bandage), is very convenient after the more serious operations. An 
ordinary narrow flannel bandage is better when much pressure is 
wanted, or if the patient be unruly. The soft, elastic, woven 
bandage, known as the “ Leicester ” bandage, is even pleasanter than 
flannel. 


APPENDIX. 


527 


When absolute exclusion of light is desired, it is best to use a 
bandage made of a double fold of some thin black material. 

Fine old linen is better than lint for laying next the skin in 
dressings after operation. 

The Moor field s’ eye bandage is made of a double fold of linen, 
seven or eight inches in length and three in breadth. It may be 
described as consisting of two squares joined together by a narrower 
strip, which fits like a spectacle-frame over the bridge of the nose. 
The four tapes are arranged so as to form two loops, into which the 
ears fit when the bandage is applied; these loops terminate in free 


Fig. 184. 



ends, which are crossed behind the head, brought forward, and tied 
in a knot over the forehead. 

52. Shades. 

As a rule, the shade should be large enough to cover both eyes, 
and should be made of some dark material, either green or black, 
and as they are readily soiled, they should be inexpensive, to per¬ 
mit of their being frequently renewed. Olive-green pasteboard or 
stout packing-paper answers the purpose admirably. A serviceable 
pattern, as shown in Figure 185, is so arranged that it fits the bridge 
of the nose. The band which encircles the head should also be of 
paper, about an inch and a half broad, and attached to the shield 
by oblique notches on its upper edge. 






































528 


APPENDIX. 


Fig. 185. 



Paper shade: A, completed shade, which consists of a, the shield ; D, the 
band. The dotted line Cis an alternate shape; B, band enlarged, showing 
oblique slit. 

53. Protective Glasses. 

Various patterns of glasses are made for the purpose of protecting 
the eyes from wind, dust, and bright light. The glasses are either 
flat, or hollow like a watch-glass, and are colored in various shades 
of blue or smoke tint. The most effectual are the ones known as 
“gogglesin these the space between the glass and the edge of the 
orbit is filled by a carefully fitting framework of fine wire gauze or 
black crape, by which side wind and light are excluded. A small 
air-pad of thin India-rubber tubing makes the frame fit still more 
closely. 

The spectacles ordinarily worn to protect the eyes from light are 
designated as coquilles, referring to their concave shape. They are 
provided, as a rule, with a non-refracting lens, of a neutral smoked 
tint of medium intensity. As many of the glasses are imperfect and 
have considerable refractive power, care should always be employed 
in their selection, to avoid irritation of the eyes from their use. 

54. Artificial Eyes. 

These are best made of glass; those manufactured from celluloid 
possess a less natural appearance and soon corrode and set up irri- 


























Y P N v 


/ 



C_| 

o 


3 

Q 

£3 

3 


cc 

H 

O 

a 

M 

7 . 

o 

o 


cr 

a 


CD 


CD 



H 

m 

(/> 

H 

r 

m 

H 

H 

n 

3 

0) 


2 

0 

n 

0 

§ 

m 

H 

5 

o 

> 

r 

D 

33 

0 

0 

JO 

n 

(/> 

(/) 

o 

z 


*\ 



APPENDIX. 


529 


tation. An artificial eye should always be removed at night, 
washed, dried, and placed in a safe place. All eyes create more or 
less irritation of the mucous membrane of the orbit, but a small 
amount of vaseline introduced into the orbit will make the move- 


Fig. 186. 



Artificial human eyes 


ments of the eye much easier and reduce the wear and tear to some 
extent. 

The following are the rules adopted by the authorities of the 
Moorfields Hospital, London, for the guidance of patients wearing 
an artificial eye: 

“To take the eye out: The lower lid must be drawn downward 
with the middle finger of the left hand; and then, with the right 
hand, the end of a small bodkin must be put beneath the lower edge 
of the artificial eye, which must be raised gently forward over the 
lower eyelid, when it will readily drop out. At this time care 
must be taken that the eye does not fall on the ground or other 
hard place, as it is very brittle, and may easily be broken by a 
fall. 

“ To put the eye in: Place the left hand flat upon the forehead, 
and with the two middle fingers raise the upper eyelid toward the 
eyebrow ; then, with the right hand, push the upper edge of the 
artificial eye beneath the upper lid, which may be allowed to drop 
upon the eye. The eye must then be supported with the middle 
fingers of the left hand, whilst the lower eyelid is raised over its 
lower edge with the right hand.” 

55. Test Types. 

Snellen’s types for testing both near and distant vision under an 
angle of five minutes may be obtained from any optician. A con¬ 
venient bracket (Fig. 187) for this display of the distant type, 
devised by Dr. Thorington, may be obtained from Wall & Ochs, of 
Philadelphia. 


34 



530 


APPENDIX. 


A convenient set of tests, small enough to be carried in the pocket, 
can be obtained through Queen & Co., Philadelphia. It consists of 
types for near and distant vision, a pupillometer for measuring the 
pupil, a set of colored stuffs for color-blindness, and a small series 
of lenses for testing refraction. This case is intended chiefly for 


Fig. 187. 



ward work and general medical cases. It may also be bought with¬ 
out the lenses. 

56. Ophthalmoscopes. 

The ophthalmoscopes usually employed in this country are the 
Loring and the Morton. 

The Loring Ophthalmoscope. This instrument consists of a full 
disk and a quadrant of a disk, as shown in Fig. 188. The quadrant 
rotates immediately over the disk and around the same centre, and 
contains 4 lenses, —.50 and —16, and -J-.50 and -f- 16. When not in 
use the quadrant is beneath its cover, and the instrument then rep¬ 
resents a simple ophthalmoscope with 16 lenses, the series running 
with an interval of 1 D., and extending from 1 to 7 plus and from 





















PLATE V. 





i 




II a. 




II b. 
































APPENDIX. 


531 


1 to 8 minus. If the higher numbers are desired, they are obtained 
by combination with those of the quadrant. These progress regu¬ 
larly up to 16 D., every dioptric being marked upon the disk; above 


Fig. 188. 



The Loring ophthalmoscope. 


this up to + 23 D. and — 24 D. it is necessary to add the glass which 
comes beneath the 16 D., turning always in the same direction. 

The Morton Ophthalmoscope. This instrument consists essentially 










































532 


APPENDIX. 


of 29 separate lenses, inclosed in an endless groove and propelled by 
a strong driving-wheel. In addition to the lenses just mentioned, 


Ftg. 189. 



The Morton ophthalmoscope. 


are four others, set in a separate disk, and so placed tliat they can be 
instantly put in front of, or removed away from, the sight-hole 
without rotating the whole series of convex or concave lenses. At 





















































































































APPENDIX. 


533 


the same time that the driving-wheel propels the lenses it rotates a 
disk, on which at a certain aperture is indicated the lens presented 
at the sight-hole. On the front of the instrument is an arrangement 
similar to the nose-piece of a microscope, revolving on a central 
pivot and carrying three mirrors—one plane and one concave mirror 
of 10-inch focus at one end, and a small concave mirror of 3-inch 
focus at the other. The first two, which are set back to back in one 
mounting and are reversible, are for indirect examination and reti- 
noscopy. The advantages claimed for this ophthalmoscope are 
briefly : 1. A continuous series of single lenses sufficient for all ordi¬ 
nary purposes. 2. The provision of a few separate, easily adjust¬ 
able lenses for extraordinary cases. 3. The lens in the sight-hole 
is always shown on the indicating disk (except in the rare cases 
in which one of the extra lenses just mentioned is used). 4. The 
numbers of the lenses and their relative positions being fully ex¬ 
posed on an indicating disk, the direction in which this latter has to 
be rotated to bring any particular lens to the sight-hole is at once 
made manifest. 5. There is only one driving-wheel. 6. A pupil- 
meter, which is set in the face of the driving-wheel. 7. The pro¬ 
vision of two mirrors revolving on a central pivot, so that either can 
be at once brought into position. 8. The width of the instrument 
is only 1J inches, while the driving-wheel, being 3 inches below the 
sight-hole, is unimpeded in its action by contact with the face of 
the observer or patient. 9. Lastly, the instrument balances well in 
the hand, is light, and packs into a small compass. 

57. Perimeters. 

The McHardy Perimeter. This instrument, which is undoubtedly 
the most complete and accurate perimeter in use, consists of a quad¬ 
rant of 30 m. radius and 75 mm. wide. This quadrant is divided 
into single degrees, and carries a movable slide or carriage, which 
is connected by clock cord to a series of pulleys. These are set in 
motion by a train of gear-wheels so arranged as to move a pin in 
proportionate ratio to the motion of the slide on the quadrant. 
The chart is clamped in a neat holder, which is pressed against the 
pin, the range of vision being registered in each meridian. The 
meridian is indicated by a pointer fixed to the disk in the centre of 
the instrument, which is divided into five degrees. The stand holds 
an upright bar, on which are the chin- and eye-rests; these are used 
to keep the patient’s face and eye in a steady position, the chin-rest 
having a vertical adjustment. 


534 


APPENDIX. 


Fig. 191. 




jffi 

Iji 

jjj 

jjn 

ill 

111 

III III 

ill 

| 


McHardy perimeter. 


Another excellent and much cheaper instrument is the Meyrowitz. 
This instrument combines the most practical points of the Landolt 
and the Priestley-Smith perimeters. It is light and well balanced, 
and has the broad metal arc, with the sliding object-carrier of the 
Landolt and the registering attachment of the Priestley Smith 
instrument. It has an adjustable double chin-rest, sliding upon an 
upright bar, the end of which carries a rubber plate and determines 
the point of fixation. The chart is fitted to a hard rubber disk at 
the back of the instrument and is revolved with the arc. A sta¬ 
tionary scale, mounted upon an upright arm, is graduated to corre¬ 
spond to the divisions of the arc, and is placed immediately back 
of the disk holding the chart. By means of this ingenious combi- 





























































APPENDIX. 


535 


nation the exact position of the object point upon the arc and the 

Fig. 192. 



Astigmatic dial. 


meridian of the arc itself may be pricked upon the chart by a single 
puncture. 

58. Type for ascertaining the range of accommodation (Wall 
& Ochs). 











REQUIREMENTS OF CANDIDATES FOR ADMIS¬ 
SION INTO THE PUBLIC SERVICES IN 
THE UNITED STATES OF AMERICA. 


Commission in the Army. The line corps of the army is recruited 
from the Military Academy at West Point, N. Y., where at entrance 
as well as at graduation the vision, as determined by the official test 
types, must not fall below in either eye, and not below unless 
it can be made normal by proper glasses. Color blindness is not a 
cause for rejection, but must be noted upon the form for physical 
examination and the applicant so informed. 

For admission into the medical corps of the army, errors of refrac¬ 
tion, when not excessive and not accompanied by ocular disease, and 
when correctable by appropriate glasses, are not causes for rejection. 

Recruiting officers are guided in the examination of applicants 
for enlistment into the ranks of the United States Army by Tripler’s 
Manual. As specified in an epitome of this work, prepared by 
Major Charles R. Greenleaf, the following ocular defects are noted 
as causes for absolute rejection: 

Loss of either eye. 

Chronic inflammation of the lids, which may be known by their 
being red and swollen, with collections of more or less dried matter 
on the edges between and around the lashes; the ball of the eye 
will also be “bloodshot.” 

Inability to count with facility, at twenty feet distance, the black 
spots on the test cards. This examination requires the greatest care 
and patience on the part of the recruiting officer ; it is made with 
test cards, “ ten in number, with black spots arranged like those on 
playing-cards, and ranging from 1 to 10 on each card. The spots 
are circular, and each four-tenths of an inch in diameter.” The 
recruit must be able to count them with facility at twenty feet dis¬ 
tance. Each dot presents the same appearance, when seen by the 
normal eye at this distance, as a black centre three feet in diameter 
on a white ground at six hundred yards’ distance. To use these 
cards, measure off a line twenty feet long on the floor of a well- 
(536) 



APPENDIX. 


537 


lighted room. Stand the recruit with his toes at one extremity of 
the line. Let an assistant, holding the pack of cards in his hands, 
stand with his toes r.t the other extremity of the line and expose 
successively the faces of two or three of the cards. The recruit 
must be able to state promptly the number of dots on each. This 
examination must be made with each eye separately. The exami¬ 
nation may be varied, by showing to the recruit one of the higher 
numbers, such as the nine or ten card, and covering up a part of its 
face with another card so as to expose one or more spots at a time. 
The “assistant” in this case should be the recruiting-officer; and 
the sergeant should stand behind the recruit, covering one eye com¬ 
pletely with a card. It is a custom to cover the eye with the hand ; 
this is very objectionable, because, unconsciously, more or less press¬ 
ure is made upon the organ, and such a sense of discomfort, as well 
as disorder in the circulation, produced that clearness of vision 
when the eye is uncovered is much interfered with ; or, a designing 
man may take advantage of an opening between the fingers of the 
hand placed over his eye to see to read the cards, while the other 
eye may be totally defective. The applicant should stand with his 
face to the light, because in this position the iris is contracted and 
the pupil becomes so small that any defect of the cornea (or glass 
of the eye), which may be situated directly in front of the pupil, 
will so interfere with vision as to be discovered. If the light falls 
from behind the applicant, or he is in shadow, the iris is relaxed and 
the pupil dilates sufficiently to allow the rays of light to enter the 
eyes by the side of a defect, and vision seems to be perfect, while in 
reality it may be very imperfect. There is often considerable hesi¬ 
tation on the part of the applicant in counting the spots, which may 
be due to ignorance, and some of the low numbers should be pre¬ 
sented to him. It is better to begin the examination with the right 
eye, and the spots on at least six cards should be counted without 
hesitation before it can be considered satisfactory ; failing in this, the 
applicant should be rejected. 

Prominence of the eyeballs to such an extent as to prevent tlve 
lids from closing (exophthalmos); drooping of the upper lids over 
the eyeballs, with inability to raise them (ptosis) ; adhesion of the 
lids to the eyeballs ; scalding of the cheeks from tears, indicating 
closure of the tear-duct; cross-eye, or squint of the right eye, if 
permanent or well-marked (strabismus): are all causes for disqualifi¬ 
cation. 

The following defects, if discovered, should be noted on the en- 


538 


APPENDIX. 


listment papers of the recruit by the recruiting officer, and the 
question of rejection left to the decision of the surgeon at the depot. 

A film across the white of the eye, pyramidal in shape, the base 
resting on or near the “sight” (pterygium). 

Milky opacities on the cornea (leucoma). 

Wavering and divergence, generally outward, of one or both eyes 
when the applicant is required to look steadily at an object, say the 
hand or fingers, held at a distance of six or eight inches from the 
face (asthenopia). 

A rotary or oscillating movement of one or both eyes when look¬ 
ing at an object at the ordinary visual distance (nystagmus); both 
eyes are generally affected, and the nervous character of the disease 
is shown by the increased motion during the examination. 

Double vision, or that condition of sight in which two images 
instead of one are seen when the applicant is required to look stead¬ 
ily at an object (diplopia). 

Commission in the Navy. The line corps of the navy is recruited from 
the Naval Academy at Annapolis, Md., where a vision below in 
either eye is a cause for rejection. No correcting lenses may be worn 
at the time of the test. Normal color-perception is essential. At 
graduation the standard for acuteness of vision is the same as at 
entrance, and no correcting lenses are allowable. 

Visual acuity is obtained by means of the Snellen test-types, and 
the Holmgren method is used for testing the color-sense. 

Merchant Marine ( Masters , Mates, and Pilots). There are no es¬ 
tablished rules for testing eyesight of the Board of Supervising 
Inspectors other than for color-blindness, the determination of other 
defects and the decision regarding the proper qualifications of each 
candidate being at the discretion of the local inspectors. It is gen¬ 
erally understood, however, although not rigidly insisted upon, that 
in addition to normal color-perception, which is tested by Holmgren’s 
skeins, there must be a visual acuity in each eye of as obtained 
by the Snellen test-types. 


METHOD OF EXAMINING THE EYES OF 
SCHOLARS IN THE PUBLIC SCHOOLS 
IN CERTAIN AMERICAN CITIES . 1 


The actual tests in this method are made by the principals and 
teachers in the various schools, upon account of the impossibility 
of securing, as yet, the appointment of properly equipped medical 
men for this purpose. There should, however, be a supervisor, a 
trained oculist, with a competent corps of assistants, to whom all 
doubtful cases should be referred. He should also instruct the teach¬ 
ers regarding the manner in which they should make the tests, and 
should explain to them briefly the salient points of ocular hygiene. 

The eyes of all the children should be tested at the commence¬ 
ment of the school term, and if the vision or range of accommoda¬ 
tion of either eye be found below the standard, or if symptoms of 
ocular fatigue be complained of, the parents or guardian should be 
so informed, and further examination and treatment by an oculist 
insisted upon. 

All that is required for examining the eyes are two charts ot 
Snellen test-letters, one of large letters, for determining the degree 
of visual acuity; the other, of small type, to ascertain the power 
of accommodation. The practical method of using these charts is 
as follows: 

1. To Test the Visual Acuity. Place the large letters in a good 
light twenty feet away from the scholar, and ascertain the lowest 
line of letters which can be read, each eye being tested separately. 

2. To Test the Range of Accommodation. The nearest point at 
which the finest type (that marked 0.50 V.) can be read clearly with 
each eye separately should be ascertained, and should be compared 
with a table printed on the back of the card, showing the proper 
near point for a normal eye at all ages ranging from five to twenty 

1 This method of examination is practically the same as that introduced 
by Dr. Frank Allport some years ago, and which is now in successful oper¬ 
ation in Chicago. 

( 539 ) 



540 


APPENDIX. 


years. Brief instructions as to the manner of obtaining the accom¬ 
modation should also be appended. 

The superintending oculist with his assistants should be appointed 
by the Board of Education, and should be required to report to that 
body the result of the teachers’ examinations. For professional 
reasons, great care should be exercised regarding the manner in 
which the parents or guardian are told to consult an oculist, and a 
list of the different eye dispensaries in the same district as that in 
which the pupil lives should be furnished them. 


INDEX. 


A. 

Abbreviations, 17 
Abduction, measurement of, 52 
Abscess of lachrymal sac, 97 
Accommodation, 329 
after blows, 322 
amplitude of, 50 
association with convergence, 
50 

in hypermetropia, 345 
micropsia due to insufficiency 
of, 281 

paralysis of, 388 
in presbyopia, 361 
relative, 51 

restriction of, in dental dis¬ 
orders, 476 
spasm of, 277 
in myopia, 333 
tests for, 50 

Adduction, measurement of, 53 
Adenoma of lachrymal gland, 95 
Albinism, 228 

Albuminuric retinitis, 241, 457 
Alum, preparation of, 515 
Amaurosis, 269 
hysterical, 277 
in optic atrophy, 267 
Amblyopia, 269 
after blows, 278 
alcohol in, 274, 455 
in anisometropia, 271 
in astigmatism, 271 
central scotoma in, 273 
congenital, 281 

from defective retinal images, 
271 

suppression of image, 269 
in dental disorders, 476 
double central in, 274 
glasses in, 271 
in hypermetropia, 270 
hysterical, 277 
ophthalmoscope in, 272 


Amblyopia in strabismus, 269 
strychnine in, 274 
tobacco in, 274, 455 
Ametropia, 329 
hysteria in, 278 

Amplitude of accommodation, 50 
Amyloid conjunctivitis, 121, 122 
Anaemia a cause of blepharitis, 
86 

in corneal ulceration, 128 
optic neuritis in, 261 
pernicious, progressive, 459 
retinitis of, 244, 246 
secondary, 461 
Anaesthetics, 444 

Aneurism of intra-orhital vessels, 
326 

Angular gyrus, disease of, lieini- 
anopia in, 276 
Anisometropia, 360 
amblyopia in, 271 
Anterior chamber in glaucoma, 
292, 294, 295, 298 
paracentesis of, 421 
Aqueous humor, evacuation of, in 
glaucoma, 304 
Arcus senilis, 151 
Argyll-Robertson symptom, 472 
Army, visual standard in, 535 
Artificial eyes, 528 
Asthenopia, 278 
accommodation, 278 
after accidents, 279 
astigmatism in, 279 
causes of, 279 
fifth-nerve in, 279 
headache in, 278 
hypermetropia in, 279, 347 
muscular, 278 
in myopia, 332 
treatment of, 279 
Astigmatism, 351 
after blows, 183 

extraction of cataract, 209 
operations, 353 


541 






542 


INDEX. 


Astigmatism, amblyopia in, 271 
asthenopia in, 279 
in cataract, 192 
cornea in, 352 

determination of, by ophalmo- 
scope, 73 

by shadow-test, 76, 78 
disk in, 355 
focal interval in, 352 
image in, 355 
irregular, 352 
lenses in, 355 
lens in, 352 

ophthalmometer in measuring, 
54 

ophthalmoscope in, 355 
principal meridians in, 352 
regular, 352 
retinoscopy in, 355 
symptoms of, 354 
tests foi’, 355 
Atropine, 520 
action of, 386 
in hypermetropia, 349 

B. 

Bacillus of Weeks, 108 
Bandages, 526 
Basedow’s disease, 473 
Belladonna fomentations, 523 
“ Black eye,” 321 
Blepharitis, 85 
after measles, 452 
anremia a cause of, 86 
causes of, 86 
epiphora a result of, 86 
measles a cause of, 86 
scrofula a cause of, 86 
sequel® of, 86 

slitting of canaliculus in, 87 
symptoms of, 85 
treatment, of, 87 
types of, 85 
Blepharospasm, 127 
Blindness from exposure to light, 
124 

red-green, 284 
Bloodvessels of eyeball, 39 
of retina, 65, 67 
appearance of, 68 
obstruction of, 65 
Boric acid, 516 

Brain, involvement of, in glioma, 
315 

syphilis of, 448 


Brain, tumors of, in ocular paraly¬ 
sis, 389 

optic neuritis in, 260 
Bright’s disease in retinitis, 241 
Buller’s shield, 103 
Buphthalmos, 150 

c. 

Canaliculus, Bowman’s opera¬ 
tion on, 407 
obstruction of, 96 
slitting the, 407 
in blepharitis, 87 
Cancer, rodent, of eyelids, 90 
treatment of, 92 
Canthoplasty, 404 
Capsulitis after extraction of 
cataract, 208 

Capsulo-pupillary membrane, 163 
Carbolic-acid lotion, 517 
Carbon, bisulphide of, 456 
Cardiac disease in retinitis, 247 
Caruncle, after treatment of stra¬ 
bismus, 376 
papilloma of, 311 
tumors of, 311, 312 
Cataract, 191 
after choroiditis, 197 
disease of vitreous, 197 
intraocular tumors, 197 
iridocyclitis, 197 
retinitis pigmentosa, 197 
serous cyclitis, 171 
ulceration of cornea, 196 
amblyopia after extraction of, 
271 

astigmatism in, 192 
in children, 200 
choroiditis as a cause of, 192 
ciliary body in, 192 
complicated, 197 
concussion, 209 
congenital, 193, 201 
consistence of, 192 
cortical, 192, 198 
dotted, 193 

in detachment of retina, 197 
diabetes in, 191 
diagnosis of, 197 
discission of, 203, 441 
drugs as a cause of, 192 
etiology of, 191 

examination of, by focal illumi¬ 
nation, 198 
extraction of, 432 



INDEX. 


543 


Cataract, extraction of, after-treat¬ 
ment of, 438 
astigmatism after, 209 
capsulitis after. 208 
causes of failure after, 206 
complications during, 438 
conical section in, 436 
cyclitis after, 208 
dacryo-cystitis in, 206 
galvano-cautery after, 207 
glasses after, 209 
hemorrhage after, 181, 206 
hypermetropia after, 209 
incarceration of iris after, 208 
iritis after, 207 
keratitis after, 208 
lens in, 203 

membrane in pupil after, 207 
modified linear, 432, 434 
by old flap method, 436 
panophthalmitis after, 207 
preliminary iridectomy in, 
434 

prolapse of iris after, 208 
shield after, 439 
by short flaps, 435 
sight after, 208 
simple linear, 434 
by suction, 443 
suppuration after, 206 
treatment of, 206 
focal illumination in, 198-200 
following injury, 209 
from diabetes, 458 
glass-blowing in, 192 
glaucoma complicating, 197, 308 
hard, 193 
heredity in, 192 
immature nuclear, 198 
incipient, 198 
lamellar, 194, 200, 209 
teeth in, 478 
light perception in, 198 
loss of sight in, 198 
mixed, 193 
Morgagnian, 202 
myopia in, 198 
nephritis in, 192 
nuclear, 192 
operations after, 440 
for, 203 

iritis in, 160 
partial, 191 

perception of light in, 198 
polar, anterior, 196 
posterior, 196, 200 


Cataract, polyopia in, 198 
primary, 197 
prognosis of, 202 
projection of light in, 198 
pupil in, 198 
pyramidal, 195 
rachitis in, 192, 194 
removal of, by curette, 204 
by suction syringe, 204 
secondary, 197 
in cyclitis, 165 
iritis in, 160 

senile, erythropsia after, 281 
skin affections in, 192 
soft, 192 

symptoms of, 197 
traumatic, 187, 189, 210 
glaucoma in, 210, 309 
treatment of, 210 
treatment of, 203 
zonular, 194, 200 
teeth in, 194 

Catarrh of conjunctiva, 122 
spring, 121 

Cavernous sinus, thrombosis of, 
323 

Cellulitis of orbit, 322 
Central nervous system, disease 
of, 468 

Cerebral disease, optic neuritis in, 
255 

tumor, papillitis in, 468 
Chalazion, 88 
causes of, 88 
symptoms of, 88 
treatment of, 89 
Chancre of eyelids, 92, 311, 447 
Chiasma, diseases of, hemianopia 
in, 275 

optic neuritis in, 261 
tumor of, optic atrophy in, 
267 

Chicken-pox, 452 
Choked disk, 255, 256 
Chorea in retinitis, 247 
Choroid, appearance of, in health, 
214 

atrophy of, 215 
complete, 218 
partial, 218 
signs of, 216, 217 
superficial, 218 
colloid disease of, 219 
coloboma of, 228 
congestion of, 227 
diseases of, 213 



544 


INDEX. 


Choroid, diseases of, after blows, 
227 

hemorrhage, 227 
clinical forms of, 221 
in myopia, 213 
optlialmoscopic signs of, 215 
pigment in, 213 
retina in, 213 

in diseases of vitreous, 286 
elastic lamina of, 220 
hemorrhage of, 180, 182, 220 
miliary tuberculosis of, 219 
in myopia, 334 
nsevus of, 328 

pigmentation of, after albu¬ 
minuric retinitis, 227 
in pyeemia, 454 
rupture of, 181, 219 
sarcoma of, 316 
liver in, 317 
structure of, 214 
syphilis of, 227, 448 
tubercular growths of, 227, 462 
Choroiditis after infection, 226 
pysemia, 226 
anomalous forms of, 226 
anterior, 168 

atrophy of optic nerve in, 222 
cataract after, 197 
as a cause of cataract, 192 
central senile, 224 
disseminata, 221, 223 
exudation into vitreous in, 226 
from meningitis, 226, 453 
thrombosis of orbital veins, 
226 

haze of vitreous in, 223 
iritis in, 160, 223 
metastatic, 226, 476 
myopia in, 223 
panophthalmitis after, 226 
posterior staphyloma in, 224 
pseudo-glioma after, 226 
recent, 218 
in serous cyclitis, 170 
suppurative, 226 
syphilitic, 218, 222 
Tays’, 226 
treatment of, 223 
Choroido-retinitis in diseases of 
vitreous, 288 
Cilia, misplaced, 119 
treatment of, 121 
electrolysis in, 121 
Ciliary body in cataract, 192 
in glaucoma, 300 


Ciliary body, inflammation of, 
after injury, 172 
sarcoma of, 316 
in serous cyclitis, 170 
in sympathetic ophthalmia, 
173 

syphilis of, 448 
congestion, 41, 153 
in serous cyclitis, 171 
muscle in hypermetropia, 345 
in myopia, 338 
paralysis of, after blows, 182 
nerves, 173 

in glaucoma, 298 
region, 165, 167 
diseases of, 165 
staphyloma, 169 

Circumcorneal congestion, 153 

Cocaine, 518 
action of, 386 

Cold, 525 

Coloboma of choroid, 228 
/fff iris, 163 

' of* lpim 910 

Color-blindness, 283, 479 
acquired, 283 
confusion colors in, 284 
congenital, 283 
detection of, 284 
heredity in, 283 
Holmgren’s test for, 481 
lantern-test for, 500 
new wool-test for, 495 
in optic atrophy, 265 
partial, 283 

Thomson’s test for, 482 
total, 283 

Color perception, tests for, 57 
sense, tests for, 487 

Compresses, 525 

Concave mirrow in shadow-test, 
76, 78 

Conical cornea, 149 

Conjunctiva, 37 
after chicken-pox, 452 
measles, 452 
amyloid disease of, 122 
burns of, 184 
cauliflower warts of, 31 
chemosis of, in cellulitis of orbit, 
322 

cysts of, 313, 314 
diphtheria of, 451 
diseases of, 101 
in eczema of face, 110 
effect of electric light on, 124 



INDEX. 


545 


Conjunctiva, epithelioma of, 314 
in erysipelas, 110 
external examination of, 37 
fibro-fatty tumors of, 313 
foreign bodies in, 184 
in glaucoma, 294 
hemorrhage from, 108 
in whooping-cough, 453 
in herpes zoster, 110 
in leprosy, 466 
lupus of, 311 
lymphoma of, 109 
in measles. 110 
moles of, 313 
pemphigus of, 123 
in rupture of eyeball, 180 
scalds of, 184 
scarlet fever in, 451 
shrinking of, 122 
smallpox of, 450 
spring catarrh of, 122 
syphilis of, 447 
tubercle of, 92 
tuberculosis of, 311 
treatment of, 311 
wounds of, 323 
penetrating, 323 
xerosis of, 124 
Conjunctivitis, 101 

acute contagious, zinc chloride 
in, 109 
amyloid, 121 
caruncle in, 121 
catarrhal, 107 
acute, 107 
chronic, 121 
croupous, 111 
diptheritic, 111 
antitoxin in, 113 
treatment of, 111 
epidemic, 108 

treatment of, 108 
follicular, 110 
from drugs, 122 
intense light, 124 
gonorrhoeal, 464 
granular, 113 

as a cause of keratitis, 132 
enlargement of papill® in, 
113 

expression in, 117 
galvano-cautery in, 117 
jeguirity in, 120 
nitrate of silver in, 117 
opacity of cornea in, 118 
prevention of, 116 

35 


Conjunctivitis, granular, results 
of, 117 

roller forceps in, 117 
treatment of, 116 
lachrymal, 121 
marginal, 131 
membranous, 111 

corneal ulceration in, 111 
nodosa, 123 
Parinaud’s, 109 
purulent, 101 

cold applications in, 108 
corneal ulceration in, 103 
gonococcus in, 101 
to inspect cornea in, 394 
nitrate of silver in, 105 
protargol in, 105 
treatment of, 103 
rheumatic, 110, 463 
simple acute, 107 
Constipation in diseases of vitre¬ 
ous, 289 

Convergence, accommodation as¬ 
sociated with, 50 
insufficiency of, in myopia, 332 
in strabismus, 375 
Copper, sulphate of, 514 
Coquelles, 528 
Coredialysis, 181 
Cornea, 42 

abrasions of, 183 
hypopyon in, 164 
treatment of, 184 
abscess of, 134 

after paralysis of fifth nerve, 
474 

anaesthesia of, in glaucoma, 298 

in astigmatism, 352 

blisters on, 132 

bullae of, 183 

burns of, 184 

cauterization of, 422 

conical, 149 

concave glasses in, 150 
operations for, 423 
detection of irregularities in 
surface of, 42 
in disease of orbit, 323 
diseases of, 125 

effect of quinine lotions on, 126 
febrile herpes of, 136 
fluorescence of, 126 
foreign bodies in, 183 
detection of, 60 
removal of, 420 
in glaucoma, 292 




546 


INDEX. 


Cornea, hypopyon ulcer of, section 
for, 422 

inflammation of, 125 
cyclitis, 143 
diffuse, 142 
filamentary, 136 
interstitial, 142 
relapses in, 146 
results of, 145 
treatment of, 146 
iritis in, 143 
in ophthalmitis, 176 
oyster shuckers’, 137 
parenchymatous, 142 
secondary glaucoma in, 146 
to other diseases, 148 
superficial punctate, 136 
symptoms of, 125 
syphilitic, 142 
treatment of, 137 
injury of, iritis in, 184 
inspection of, in purulect con¬ 
junctivitis, 394 

involvement of, in glaucoma. 

149 

nutrition of, 125 
opacities of, 126 
congenital, 149 
in granular conjunctivitis, 
118 

in myopia, 339 
results of, 126 
treatment of, 126 
calomel, 126 
electrolysis, 126 
massage, 126 
tattooing, 126 
transplantation, 126 
yellow oxide of mercury, 
126 

perforation of, secondary glau¬ 
coma after, 308 

punctate, deposits on back of, 
171 

scalds of, 184 
syphilis of, 448 

transverse calcareous film of, 

150 

ulcers of, 125, 128 
action of lead on, 455 
acute infective, 133 
serpiginous, 133 
anaemia in, 128 
cataract after, 196 
causes of, 125 
chronic serpiginous, 132 


Cornea, ulcers of, crescentic, 132 
dendritic creeping, 136 
exophthalmic goitre as a cause 
of, 136 

in facial palsy, 474 
from exposure, 136 
in Graves’ disease, 475 
in herpes zoster, 474 
hypopyon in, 133 
iridectomy in, 141 
lymphatic, 128 
marginal, 128 

pericorneal injection in, 127 
phlyctenular, 128, 129 
pustular, 128, 131 
recurrent vascular, 131 
relapsing bullous, 132 
rodent, 133 
strumous, 128 
treatment of, 137 
atropine in, 141 
cautery in, 140 
eserine in, 141 
heat in,139 
incision in, 140 
seton in, 139 

yellow oxide of mercury in, 

138 

vesicles of, 136 
wounds of, 186, 189 
Corneal opacities, examination of. 
58-60 

reflex, ophthalmoscope in study 
# of, 71 

Credo’s method of prevention of 
ophthalmia neonatorum, 
106 

Crus cerebri, disease of, 472 
Cyclitis after extraction of cata¬ 
ract, 208 

in corneal inflammation, 143 
in diseases of vitreous, 289 
with diseases of vitreous and 
keratitis punctata, 170 
purulent traumatic, 172 
in relapsing fever, 453 
serous, 170 

anterior chamber in, 170 
cataract after, 171 
choroiditis in, 170 
ciliary body in, 170 
congestion in, 171 
etiology of, 171 
glaucoma in, 170 
gout in, 171 
iridectomy in, 172 








INDEX. 


547 


Cyclitis, serous, iritis in, 170 
myopia in, 171 
phthisis in, 171 
pupil in, 171 
syuecliiae in, 170 
tension in, 170 
' treatment of, 172 
atropine in, 172 
vitreous in, 170 
syphilitic, 447 
Cycloplegia, 388 

after diphtheria, 451 
with mydriasis, 388 
Cysticercus cellulosae, 289, 466 
Cysts of conjunctiva, 313, 314 
dermoid, of eyeball, 313 
Meibomian (see Chalazion), 
pellucid, of eyelids, 89 

I). 

Dacryo-adenitis, 94 
acute, 94 
causes of, 94 
chronic, 94, 97 
cold in, 94 
mumps in, 94 
rheumatism in, 94 
septicaemia in, 94 
syphilis in, 94 
treatment of, 94 
poultices in, 94 

Dacryocystitis in extraction of 
cataract, 206 
in new-born infants, 100 
Dacryoliths, 96 
Dacryops, 314 
Day-blindness, 281 
Diabetes, 458 
in cataract, 191 
retinitis in, 244 
Diagnosis of cataract, 197 
Dial, astigmatic, 357 
Diarrhoea in keratomalacia, 136 
Digestion, irregularities of, as¬ 
thenopia of, 280 
Diphtheria, 451 

convergent strabismus after, 
451 

of conjunctiva, 451 
cycloplegia after, 451 
extra-ocular muscles after, 451 
Diplopia, 379 
binocular, 379 
causes of, 380 
monocular, 379 


Diplopia in myopia, 333 
in strabismus, 368 
tests for, 380 
Discission operation, 441 
Disk in astigmatism, 355 
Distichiasis, 119 
Duboisine, 521 

E. 

Echinococcus, hydatid, 467 
Ectropion, 400 
operations for, 400 
Argyll-Robertson’s, 401 
Kulint’s, 400 
Snellen’s, 400 

Eczema, marginal, of eyelids, 86 
Electrolysis for hair-follicles, 399 
Emphysema of orbital cellular 
tissue, 321 

Enophthalmos, 38, 321 
Entozoa, 466 
Entropion, 118 
operation for, 395 
organic, 395 
spasmodic, 395 
Enucleation, 416 
after foreign bodies, 189, 190 
Epicanthus, 93 
Epilation, 393 
Epiphora, 94 
causes of, 95 
in facial palsy, 474 
result of blepharitis, 86 
Episcleral tissue, diseases of, 165 
Episcleritis, 132, 165 
iritis in, 166 
phlyctenulse in, 166 
rheumatism in, 463 
Epistaxis in diseases of vitreous, 
289 

Epithelioma of conjunctiva, 314 
Erysipelas, 476 
of conjunctiva, 110 
in orbital disease, 321 
Erythropsia, 281 

fasting a cause of, 281 
senile cataract after, 281 
Eserine, 522 
action of, 386 
Esophoria, 52 

in hypermetropia, 350 
prism exercise in, 351 
Ethmoiditis, 476 
Ethmoid sinus, distention of, 325 
Eucaine, 522 



548 


INDEX. 


Evisceration, 418 
Examination, external, of con- 
juctiva, 37 
of eye, 37 

of iris, 43, 58, 59, GO 
of lens, 43, 59, 60 
of lids, 37 

of fundus by ophthalmoscope, 
74 

Exanthemata, optic neuritis in, 
261 

in phlyctenular keratitis, 124 
Exciting eye, 173 
Exophoria, 52 
prism exercise in, 350 
Exophthalmic goitre, 475 

as a cause of corneal ulcera¬ 
tion, 136 

Exophthalmos, 37 
in goitre, 475 
Exostoses, ivory, 325 
Eye, examination of deeper media. 
60 

by focal light, 58-60 
by lateral illumination, 58-60 
by oblique light, 58-60 
superficial media of, 58-60 
Eyeball, abscission of, 417 
bloodvessels of, 39, 40, 42 
burns of, 184 
dermoid cyst of, 313 
enlargement of, 37 
excision of, 416 
foreign bodies in, 187 
gumma of, 313 
injuries of. 180 

contusion and concussion, 180 
gunshot, 186, 189 
treatment of, 186 
optic neuritis after, 183 
without rupture, 181 
prognosis of, 182 
treatment of, 183 
mobility of, 45 

perforating wound of, iritis in, 
160 

result of blows on, 180 
retraction of, 38 
rupture of, 180 

conjunctiva in, 180 
shrinking after, 180 
treatment of, 180 
scalds of, 184 
tension of, 46 
after blows, 182 
estimation of, 46, 47 


Eyeball, tumors of, enucleation in, 
315 

wounds of, 183 

penetrating, 186, 189, 
treatment of, 186 
Eyelids, chancre of, 92, 447 
diseases of, 85 
eversion of upper, 393 
lupus of, 91 
marginal eczema of, 86 
operations on, 393 
van Millingen’s, 399 
pellucid cysts of, 89 
rodent cancer of, 90 
syphilis of, 447 
ulcers of, 90 
warty formations on, 89 
wounds of, 323 
penetrating, 323 

Eye muscles, external, balance of, 

51 

nomenclature of, 51 
test for, 51 

F. 

Facial nerve, paralysis of, 474 
Far-point 330 

Fifth nerve, neuralgia of, in oph¬ 
thalmitis, 176 
paralysis of, 474 
Fistula of lachrymal sac, 97 
Flags, use of, in testing color- 
sense, 488 
Fluorescine, 523 
Focal illumination, 58-60, 184 
Foeus, conjugate, 331 
Fovea centralis, 68, 230 
Frontal sinus, distention of, 325 
treatment of, 325 
Fundus, examination of, by oph¬ 
thalmoscope, 74 

G. 

Glassses, protective, 528 
Glaucoma, 291 
absolute, 295 
acute, 291, 294 
symptoms of, 294 
after influenza, 453 
anterior chamber in, 292, 294, 
295, 298 

atrophy of retina in, 294 
blindness in, 294 
cataract in, 197, 308 



INDEX. 


549 


Glaucoma, chronic, 291 
symptoms of, 292 
ciliary body in, 300 
nerves in, 298 
complicating cataract, 303 
conjunctiva in, 294 
cornea in, 292, 294, 295 
anaesthesia of, 298 
corneal involvement in, 149 
excavation of optic nerve in, 
296 

fifth nerve in, 302 
filtration angle in, 300 
scar in, 305 

general and diathetic causes, 
302 

gout in, 302, 465 
halos, 292 

heart disease in, 302 
hemorrhage in, 181, 310 
hypermetropia in, 291 
infantile, 150 
inflammation in, 293 
iridectomy for, 425 
lens in, 293, 298, 301 
lids in, 294 

ligamentum pectinatum in, 300 
loss of sight in, 292, 294, 295 
malignum, 308 
mechanism of, 299 

Brailey’s theory of, 301 
Smith’s theory of, 301 
Weber’s theory of, 301 
in metastatic tumors, 317 
neuralgia in, 294, 467 
operations for, atropine in, 308 
diet in, 308 
indications, 305, 306 
prognosis of, 306 
sleep in, 308 
in ophthalmitis, 176 
of optic nerve in, 294 
pain in, 294, 295 
paralysis in, 302 
perforation of vessels in, 292, 
295 

permanent, 296 
premonitory stage in, 292 
presbyopia in, 292 
primary, 291 

pulsation of vessels in, 293 
pupil in, 292, 294, 295, 298 
remittent, 294 
retinal vessels in, 297 
sclerotic in, 291 
sclerotomy for, 430 


Glaucoma, secondary, 291, 308 
acute, 308 

after detached retina, 309 
dislocation of lens, 309 
intra-ocular tumors in, 309 
iritis, 157 

hemorrhage into eye, 309 
perforations of cornea, 308 
traumatic cataract, 309 
chronic, 308 

in corneal inflammation, 146 
in serous cyclitis, 170 
simple, 293 

symptoms, explanation of, 295 
subacute, 291, 293 
symptoms of, 294 
tension in, 292, 294, 295 
in traumatic cataract, 210 
treatment of, 303 
cocaine in, 304 
eserine in, 303, 308 
evacuation of aqueous humor 
in, 304 

iridectomy in, 303 
leeching in, 304 
pilocarpine in, 303, 308 
puncture of sclerotic in, 304 
tumors in, 301 
vessels of retina in, 297 
vision in, 292, 294, 295 
visual field in, 292, 295 
Glioma of optic nerve, 315 
of retina, 315 

Gonorrhoeal rheumatism, 463 
Gout, 465 

in diseases of vitreous, 289 
in glaucoma, 302 
in iritis, 159 
in scleritis, 166 
in serous cyclitis, 171 
Graefe’s sign, 475 
Graves’ disease, 475 
Gumma of eyeball, 313 

intracranial, optic neuritis in, 
261 

of iris, 320 
of orbit, 324 

Gummatous scleritis, 168 
Gunshot injuries, 186, 189 

H. 

Head, injuries of, in ocular paral¬ 
ysis, 389 

Hearing, test for, in railway em¬ 
ployes, 488 






550 


INDEX. 


Heart disease, 461 
in glaucoma, 302 
pulsation of retinal vessels 
from, 461 
Heat, 525 
Hematropine, 522 
Hemeralopia, 281 
in scurvy, 460 
Hemianopia, 275 
for colors, 277 
crossed, 277 

in detachment of retina, 275 
double, 277 
fixation-point in, 275 
in disease of angular gyrus, 276 
of chiasma, 275 
of occipital lobe, 276 
of pupillary reaction in, 276 
of tract, 276 
hysterical, 277 
line of separation in, 275 
nasal, 277 
optic disk in, 277 
in retinal hemorrhage, 275 
temporal, 277 
transient, 467 
with hemiplegia, 277 
Hemiplegia with hemianopia, 277 
Herpes of cornea, 136 
zoster, 474 
of conjunctiva, 110 
Heterophoria, 52, 376 
prism in, 376 
Maddox rod in, 377 
Holocaine, 522 
Hydrocephalus, 470 
Hydrophthalmos (see Buplithal- 
mos). 

Hypermetropia, 344 
accommodation in, 345 
acquired, 346 

after extraction of cataract, 209 
amblyopia in, 270 
asthenopia in, 279, 347 
atropine in, 349 
axial, 344 

ciliary muscle in, 345 
convergent strabismus in, 348 
convex lenses in, 346, 348 
determination of, by ophthal¬ 
moscope, 71 
by shadow-test, 76, 78 
esophoria in, 350 
glaucoma in, 291 
images in, 345 
latent, 348 


H^ypermetropia, manifest, 348 
ophthalmoscope in, 350 
in strabismus, 371 
symptoms of, 347 
treatment of, 348 
Hyperphoria, 52 

Hypertrophy of lachrymal gland, 
95 

Hyphsema, 153 
Hypopyon, 153 

in corneal ulceration, 133 
in iritis, 159 
treatment of, 140 
ulcer of cornea, section for, 442 
Hysteria, 277 
in ametropia, 278 
anaesthesia of retina in, 277 
in asthenopia, 278 
contraction of visual field in, 
277 

lachrymation in, 277 
ocular paralysis in, 390 
photophobia in, 277 
prognosis in, 278 
pupil in, 278 

spasm of accommodation in, 277 

I. 

Images, 23, 328, 329, 334 
in astigmatism, 355 
crossed, 367 

false, in strabismus, 368 
in hypermetropia, 345 
retinal, 31 
in strabismus, 365 
suppression of, 270, 373 
Inflammation, sympathetic, 173 
Influenza, 453 

Infraduction, measurement of, 53 
Intracranial disease, optic neuri¬ 
tis in, 261 

syphilitic disease, 469 
Intra-ocular hemorrhage, glau¬ 
coma after, 309 
tumors, detection of, 60 
Iridectomy in corneal ulceration, 
141 

in glaucoma, 303, 425, 427 
hemorrhage after, 181, 430 
in interstitial keratitis, 147 
in iritis, 162 

preliminary, in cataract extrac¬ 
tion, 434 

in serous cyclitis, 172 
Irideremia, 163 





INDEX. 


551 


Iridochoroiditis, 226 
chronic serous, 170 
plastic, 160 

in sympathetic inflammation, 
176 

Iridodesis, 425 

Iridocyclitis, cataract after, 197 
gouty, 465 
traumatic, 172 
Iridoplegia, 387 
reflex, 387, 471 
Iridotomy, 427 
Iris, 43 

absence of, 163 

artificial pupil, operation for, 
424 

cleft in, 163 
coloboma of, 163 
detachment of, 181 
in diabetes, 459 
diseases of, 153 
examination of, 58-60 
external examination of, 43 
foreign bodies in, 187 
gumma of, 320 

incarceration of, after extraction 
of cataract, 208 
iridectomy for glaucoma, 425 
iridodesis, 425 
iridotomy, 427 
operations on, 424 
paralysis of, after blows, 182 
prolapse of, after extraction of 
cataract, 208 
treatment of, 190 
sarcoma of, 319 
syphilis of, 447 
tremulous, 181 
tubercle of, 320 
wounds of, 186 
Iritis, 153 
acute, 158 

after cataract operations, 160 
corneal abrasions, 160 
extraction of cataract, 207 
influenza, 453 
perforating wounds, 160 
smallpox, 450 
atropine in, 154, 155 
causes of, 153, 158 
gout, 159 
injuries, 160 
rheumatism, 159 
syphilis, 158 
in choroiditis, 160, 223 
chronic, in children, 160 


Iritis in corneal inflammation, 143 
ulcers, 161 

in deep-seated diseases of eye, 
161 

for dental disorders, 476 
diagnosed from glaucoma. 292 
in diseases of vitreous, 160 
duration of, 156 
exudation in, 153 
in episcleritis, 166 
examination of iris in, 58-60 
gonorrhoeal, 464 
gout in, 465 
liyphsema in, 153 
hypopyon in, 153 
in injury of cornea, 184 
intra-uterine, 164 
iridectomy in, 162 
opacities in, 161 
pain in, 156 

in panophthalmitis, 160 
pupil in, 154 
relapses in, 157 
results of, 156 
rheumatism in, 463 
in seconday cataract, 160 
secondary glaucoma after, 157 
serous, 155 
cvclitis, 170 
suppurative, 160 
in sympathetic ophthalmia, 153 
tension in, 154 
traumatic, 160, 172 
treatment of, 163 
treatment of, 161 
tubercular, 160 
in wounds of eyeball, 160 
of lens capsule, 160 

Irritation, sympathetic, 173 

J. 

Jequirity, 524 

in granular conjunctivitis, 120 

K. 

Keratitis (see Corneal Inflam¬ 
mation, 128 et seq.). 
after extraction of cataract, 208 
measles, 452 
whooping-cough, 452 
interstitial, iridectomy in, 147 
marginal, 131 
punctata, 148, 170 
in ophthalmitis, 178 



552 


INDEX. 


Keratitis, syphilis in, 147 
Keratomalacia, 135 
diarrhoea in, 136 
treatment of, eserine in, 141 
Kidney disease, 457 

L. 

Lachrymal abscess, 97 
symptoms of, 97 
treatment of, 97 
conjunctivitis, 121 
disease as a cause of conjuncti¬ 
vitis, 121 
fistula, 97 

gland, adenoma of, 95 
after mumps, 452 
diseases of [see Dacryo-ade¬ 
nitis). 

extirpation of, 99, 410 
hypertrophy of, 95 
neoplasms of, 95 
sarcoma of, 95 
tumors of, 324 

obstruction from nasal disease, 
476 

sac, distention of, 97 
excision of, 99 
tumors of, 315 
Lachrymation, 94 
Lamellar cataract, 194, 200 
Lamina cribrosa, 67 
in glaucoma, 296 
Lantern in color-blindness, 500 
Lateral illumination, 58-60 
Lead lotion, 514 
Lead-poisoning, 455 
optic neuritis in, 261 
Leeching, 525 

Lens in accommodation, 329 
anterior force of, 195 
in astigmatism, 352 
capsule of, 191 
coloboma of, 212 
cortex of, 191 
dislocation of, 181 
congenital, 212 

secondary glaucoma after, 309 
equation of, 193 
examination of, 59, 60 
external examination of, 43 
extraction of, for cataract, 203 
foreign bodies in, 187 
in glaucoma, 293, 298, 301 
gradual absorption of, 203 
in myopia, 337 


Lens, nucleus of, 191 
opacity of, 181, 191 
removal of, in myopia, 343 
senile changes in, 191 
wounds of, 187, 189 
Lenses, 18, 20 
in astigmatism, 355 
bifocal, in presbyopia, 363 
convex, in hypermetropia. 346 
decentration of, 27 
numeration of spectacle, 32 
principal axis of, 21 
focus of, 21, 23 

prismatic effect of decentring, 
table showing, 27 
refractive index of, 18 
secondary axis of, 21 
Lenticular opacities, examination 
of, 58-60 
Leprosy, 466 
Leucocytlnemia, 459 
retinitis in, 244 
Leucoma, 126 

Leukaemia, retinitis of, 246 
Lids, 37 

chancres of, 311 
external examination of, 37 
in glaucoma, 294 
nsevus of, 328 
polypoid growths of, 314 
syphilitic inflammation of, 
311 

tumors of, 314 
ulcers of, 311 

Ligament, suspensory, rupture of, 
181 

Ligamentum pectinatum in glau¬ 
coma, 300 
Lippitudo, 86 
Locomotor ataxia, 449, 471 
ocular paralysis in, 389 
optic atrophy in, 266 
pupil in, 388 

Lupus of conjunctiva, 311 
of eyelids, 91 

Lymph-nodules in iritis, 158 
Lymphoma of conjunctiva, 109 

M. 

Macula, lesions of, after injuries, 
181 

lutea, 67. 230 
Maddox rod, 51 

in color-blindness, 507 
in heterophoria, 377 



INDEX. 


553 


Maddox rod in strabismus, 375 
Malaria, 453 
Malingering, 20, 282 
Marines, visual standard for, 537 
Measles, 452 

a cause of blepharitis, 80 
in phlyctenular keratitis, 129 
Megalopsia, 281 
Megrim, 461, 467 

diagnosed from glaucoma, 292 
Meibomian cyst {see Chalazion), 
removal of, 393 
gland, diseases of, 88 
Meningitis, 469 

e|)idemic cerebro-spinal, 453 
optic neuritis, 469 
Mercury, preparations of, 514 
Micropsia, 281 

due to insufficiency of accom¬ 
modation, 281 
in retinitis, 241, 281 
Mig raine, ophthalmoscopic, 383 
Miosis, 386 
paralytic, 387 

Mirrors, concave, in shadow-test, 
76, 78 

plane, in shadow-test, 76, 79, 82 
Mobility of eye, 45 
Molluscum contagiosum, 90 
Morgagnian cataract, 202 
Motor disorders, 471 
Mucocele, 97 
treatment of, 98 

curative or operative, 98 
palliative, 98 
by probing, 99 
Mumps, 452 

in dacryo-adenitis, 94 
Muscse volitantes, 281 
Muscles, action of mydriatics on, 
386 

of myotics on, 386 
conjugate, 379 

extra-ocular, abducting, prism, 
378 

adducting prism, 378 
paralysis of, 365 
intra-ocular, 385 
physiological outlines of, 386 
paralysis of external recti, 381 
oculo-motor, 383 
superior oblique, 381 
wounds of, 323 

Muscular paralysis in whooping- 
cough, 453 

Myelitis, papulitis in, 468 


Mydriasis, 386 
cycloplegia with, 388 
paralytic, 387 
spasmodic, 387 

Myopia, 329 
after blows, 183 
asthenopia in, 332 
axial, 329 
in cataract, 198 
causes of, 338 
choroid in, 334 
choroiditis in, 223 
ciliary muscle in, 338 
crescent in, 336 
of curvature, 343 
detachment of retina in, 337 
determination of, by ophthal¬ 
moscope, 71 
by shadow-test, 76, 78 
diplopia in, 333 
in diseases of choroid, 213 
of vitreous, 289 
heredity in, 338 
images in, 331 

insufficiency of convergence in, 
332 

lens in, 337 

muscse in, 281, 333 

objecive signs of, 333 

opacities of cornea in, 339 

ophthalmoscope in, 333 

presbyopia in, 337 

prism exercise in, 342 

retinoscopy in, 334 

sclera in, 333 

in serous cyclitis, 171 

spasm of accommodation in, 333 

staphyloma in, posterior, 336 

strabismus in, 332 

symptoms of, 331 

tenotomy in, 342 

treatment of, 339 

vitreous in, 337 

Myopsia, detachment of retina in, 
239 

N. 

N;evus, 328 

Nasal duct, obstruction of, 96 
naso-pharyngitis in, 96 
probing of, 407 
stricture of, 96 
incision of, 408 
scarlet fever in, 97 
smallpox in, 97 





554 


INDEX. 


Nasal duct, incision of stricture 
of, syphilis in, 96 
stye in, 99 
treatment of, 98 

Nasopharyngitis in obstruction of 
nasal duct, 96 

Navy, visual standard in, 537 
Near-point, 331 
Nebula, 126 

Nephritis in cataract, 192 
Nerves, paralysis of, fourth, 381 
sixth, 381 
third, 379, 381 
recurrent, paralysis of, 473 
Neuralgia of fifth nerve, 467 
in glaucoma, 294 

Neuritis, retro-ocular, amblyopia 
in, 272 

Neuro-retinitis in mumps, 452 
Night-blindness, 249, 280 
bacillus xerosis in, 280 
conjunctiva in, 280 
during fasting, 280 
from moonlight, 280 
in retinitis, 241 
in sailors, 280 
in soldiers, 280 
treatment of, 281 
Nose, diseases of, 476 
in tumors of orbit, 326 
Nyctalopia, endemic, 280 
scurvy, 460 
Nystagmus, 391, 473 

O. 

Oblique illumination, 58-60 
Occipital lobe, disease of, hemi- 
anopia in, 276 

palsies, faradization in, 390 
Ocular paralysis, causes of, 388 
in hysteria, 390 
injuries of head in, 389 
in locomotor ataxia, 389 
rheumatism in, 389 
syphilis in, 389 
treatment of, 390 
tumors of brain in, 389 
Oculo-motor paralysis, syphilis in, 
448 

Onyx, 134 

Opacities in media, detection of, 69 
Opaque nerve-fibres, 231 
Ophthalmia (see Conjunctivitis), 
neonatorum, 

prevention of, 10$. / j <7 


! Ophthalmia, sympathetic, 173 
accommodation, 174 
blindness in, 176 
dangerous zone in, 174 
foreign bodies in, 174 
iritis in, 174 
tumors in, 174 
tarsi (see Blepharitis). 
Ophthalmitis, enucleation in, 177 
glaucoma in, 176 
inflammation of cornea in, 176 
lens in, 176 

neuralgia of fifth nerve in, 176 
neuro-retinitis in, 177 
punctate keratitis in, 178 
sympathetic, in diseases of vit¬ 
reous, 289 
synechise in, 176 

Ophthalmometer, description of, 
53 

in measuring corneal astigma¬ 
tism, 54 

Ophthalmoplegia externa, 384 
interna, 388, 390 
Ophthalmoscope, 530 

determination of astigmatism 
by, 73, 355 

hypermetropia by, 71, 350 
myopia by, 71, 333 
refraction by, 71 
examination of fundus by, 74 
how to use, 61 

in study of corneal reflex, 71 
Ophthalmoscopic examination, 60 
dilatation of pupil in, 64 
direct method, 61, 68 
indirect method, 61, 68 
Optic atrophy associated with 
neuralgia, 467 
in heart disease, 461 
in hydrocephalus, 470 
in insular sclerosis, 473 
paralysis of insane in, 266 
pupils in, 264 
visual fields in, 264, 267 
disk (see Optic Nerve). 

appearance of, 65 
foramen, fracture of, 267 
nerve, atrophy of, 254, 262 

after fracture of optic canal, 
267 

hemorrhage into norve- 
sheaths, 267 

intracranial disease, 265 
retinitis, 237 
tumors of orbit, 267 





INDEX. 


555 


Optic nerve, clinical aspects of 
atrophy of, 263 
color-blindness in, 265 
consecutive, 258 
in disease of cord, 265 
in glaucoma, 294 
in locomotor ataxia, 266 
in paralysis of insane, 266 
post-papillitic, 258, 263 
primary, 254, 263 
pupils in, 264 
sclerosis in, 266 
in tumors of chiasma, 267 
varieties of, 263 
visual fields in, 264 
with single amaurosis, 267 
in diabetes, 459 
excavation of, in glaucoma, 
296 

in glaucoma, 293 
glioma of, 315 
in hemianopia, 277 
in orbital disease, 323 
sheath of, 254 
structure of, 254 
syphilis of, 448 
tumors of, 324 
wounds of, penetrating, 323 
neuritis, 254 

after influenza, 453 
injuries, 183 
measles, 452 
anaemia in, 261, 460 
ascending, 254 
brain tumors in, 260 
in cerebral disease, 255 
choked disk in, 255 
descending, 254 
in disease of orbit, 260 
exanthemata in, 261 
in erysipelas, 476 
from alcohol, 455 

bisulphide of carbon, 456 
lead-poisoning, 455 
quinine, 457 
tobacco, 456 

hemorrhage from stomach in, 
261 

intracranial disease in, 261 
lead-poisoning in, 261 
in malaria, 453 
meningitis in, 262, 453, 469 
ophthalmoscopic signs of, 256 
renal disease in, 260, 457 
retro-bulbar, 261 
sight in, 259 


Optic neuritis, suppression of 
menses in, 261 
syphilis in, 260, 261 
theories of prevention of, 255 
tuberculosis in, 260 
tract, disease of, hemianopia 
in, 276 

neuritis in, 261 
Optical outlines, 17 
Optico-ciliary neurotomy, 418 
Ovaries, disease of, asthenopia in, 
280 

Orbit, abscess of, 322, 327 
cellulitis of, 322 
in erysipelas, 476 
from rheumatism, 465 
disease of, erysipelas in, 321 
optic atrophy after, 267 
nerve in, 323 

thrombosis of cavernous sinus 
in, 323 

echinococcus in, 467 
foreign bodies in, 323 
fracture of, 321 
hemorrhage of, in scurvy, 460 
in whooping-cough, 453 
injuries of, 321 
in mumps, 452 
sarcoma of, 316 
tumors of, 324 
cystic, 325 
erectile, 327 
fluctuating, 327 
gummatous, 324 
hydatid, 327 

hypertrophy of cellular tissue, 
324 

ivory exostoses, 325 
of nose in, 326 
proptosis in, 324 
pulsating, 326 
solid, 327 
syphilis in, 328 
of teeth in, 326 

Orbital cellulitis from inflamma¬ 
tion of adjacent sinuses, 476 
Orthophoria, 51 

P. 

Pannus, 119 

in phlyctenular disease, 131 
treatment of, 119 
Panophthalmitis, 172 
after choroiditis, 226 

extraction of cataract, 207 







556 


INDEX. 


Panophthalmitis after extraction 
of foreign bodies, 188 
leprosy, 406 
pyaemia in, 173, 454 
symptoms of, 172 
vitreous in, 172 

Papillitis in diseases of central 
nervous system, 468 
Papilloma of caruncle, 311 
Papillo-retinitis, 260 
Papillitis, 254 

Paracentesis of anterior chamber, 
421 

Paralysis in glaucoma, 302 
Pediculus pubis, 90 
Pellucid cyst of eyelids, 89 
Perimeters, 533 

testing field of vision with, 55 
Periosteum, tumors of, 324 
Peritomy, 120, 404 
Phlyctenulae in episcleritis, 166 
Phlyctenular disease in nasal dis¬ 
orders, 476 
pannus in, 131 
inflammation, 128 
Phorometer, 48, 378 
Photophobia, 127 
Phthisis in serous cyclitis, 171 
Pinguecula, 312 
Physiological cap, 66 
Pilocarpine, 523 
Pilots, visual standard for, 537 
Pink-eye, 108 

Plane mirrow in shadow-test, 76 
Polar cataract, 196, 200 
Polyopia in cataract, 198 
Presbyopia, 361 
accommodation in, 361 
in glaucoma, 292 
lenses in, 363 
treatment of, 363 
Prismatic exercise, 350 
Prisms, 18, 19, 26 
deviation produced by, 18 
employment of, 26-28 
to expose malingering, 29 
numeration of, 36 
to remove double vision, 28 
to test ocular muscles, 28 
Proptosis, 37, 321, 324 
in goitre, 475 
with pulsation, 326 
Pseudo-glioma, 226 
Pterygium, 312 
operations for, 313 
Ptosis, congenital, 93 


Ptosis, operations for, 402 
partial, 322 
Pupils, 43 

action of ophthalmoscope in 
testing, 69 
after blows, 322 

paralysis of cervical sympa¬ 
thetic, 475 
dilatation of, 387 
artificial, operation for, 424 
associated action of, 44 
in cataract, 198 
dilatation of, after blows, 182 
examination of, 43 
exclusion of, 155 
in glaucoma, 292 
in hysteria, 278 
in iritis, 154 
irregularity of, 44 
in locomotor ataxia, 388 
membrane of, 163 
occlusion of, 155 
paralysis of, 387 
action of, 387 

reflex activity of, direct, 44 
indirect, 44 
in serous cyclitis, 171 
sphincter of, rupture of, after 
blows, 182 

Punctum lachrvmalia, diseases of, 
95 

Pupillary membrane, 163 
reaction, hemiopic, 276 
Purpura, 454 
Pyaemia, 454 

choroiditis after, 226 
in panophthalmitis, 173 
Pyramidal cataract, 194 


Q. 

Quinine, 457, 516 

R. 

Rachitis in cataract, 192, 194 
Railway employes, examination 
of vision of, 284, 479, 484 
Recti, internal, in myopia, 332 
Refraction, 329 

determination of, by ophthal¬ 
moscope, 71 
by shadow-test, 76 
of eye, 29-31 
Relapsing fever, 453 



INDEX. 


557 


Renal disease, 457 
in retinitis, 241 

Retina, anaesthesia of, in hysteria, 
277 

arteries of, 68, 229 
atrophy of, 235, 249 
in glaucoma, 294 
bloodvessels of, 65, 67 
congestion of, 231 
cysticercus under, 466 
detachment of, 181, 237 
cataract in, 197 
in diseases of vitreous, 289 
hemianopia in, 275 
in myopia, 239, 337 
secondary glaucoma after, 
309 

treatment of, 239 
in diabetes, 459 
diseases of, 229 

blindness from, 251 
clinical forms of, 240 
of choroid, 213 
gout in, 465 

ophthalmoscopic signs of, 231 
embolism of central artery of, 
246 

functional diseases of, 280 
glioma of, 315 
hemorrhage of, 180 
anaemia, 459 
in leucocythaemia, 459 
in septicaemia, 454 
ischaemia of, 249 

after whooping-cough, 452 
in malaria, 453 
in purpura, 454 
pigmentation of, 235, 249 
reflexes of, 230 
in renal disease, 457 
in scurvy, 460 
structure of, 229 
syphilis of, 448 

thrombosis of central artery of, 
246 

vein of, 244 
veins of, 68, 229 
vessels of, in glaucoma, 297 
Retinae commotio, 183 
Retinal epithelium, hyaline de¬ 
generation of, 226 
images, 31 

opacities, detection of, 60 
vessels, pulsation in, 68 
Retinitis, albuminuric, 232, 241 
detachment in, 243 


Retinitis, albuminuric, earliest 
changes in, 241 
extravasation in, 241 
hemorrhage in, 242 
papillitis in, 243 
prognosis of, 244 
symptoms.of, 244 
vessels in, 241 
apoplectica, 245 
Bright’s disease in, 241 
cardiac disease in, 247 
chorea in, 247 
circinata, 253 
consanguinity in, 251 
diabetes in, 244 
diffuse, 232 

during pregnancy, 244 
extravasation in, 233 
from intense light, 252 
hemorrhage in, 232, 235, 244 
heredity in, 251 
of leucocythaemia, 244 
of leukaemia, 246 
mercury in, 241 
micropsia in, 241, 281 
night-blindness in, 241 
oedema in, 244 
optic atrophy after, 237 
papillo-, 241 

of pernicious anaemia, 244, 246 
pigmentosa, 249 
proliferans, 252 
renal disease in, 241 
“ring scotoma” in, 241 
syphilis in, 240 
thrombosis in, 244 
vessels in, 233 
vitreous haze in, 232 
Retinoscopy (see Shadow-test), 
in astigmatism, 355 
in myopia, 334 
Rheumatism, 463 

in dacryo-adenitis, 94 
gonorrhoeal, 463 
in iritis, 158 
in ocular paralysis, 389 
in sclerit.is, 166 
Rickets, teeth in, 194 
Rontgen rays in detection of for¬ 
eign bodies, 189 

s. 

Saemisch’s operation, 140 
Salmon patch, 144 
Sarcoma of choroid, 316 



558 


INDEX. 


Sarcoma of ciliary body, 316 
of iris, 319 

of lachrymal gland, 95 
of orbit, 316 

of sclero-corneal junction, 314 
Scarlet fever, 450 

in stricture of nasal duct, 97 
Schools, examination of eyes in, 
538 

Sclera in myopia, 333 
Scleral ring, 65 
Scleritis, 165 
gout in, 166 

rheumatism in, 166, 463 
syphilis in, 167 
treatment of, 168 
Sclero-iritis, 168 
-keratitis, 168 
treatment of, 169 
Sclerosis, insular, 473 
Sclerotic, diseases of, 165 
in glaucoma, 291 
puncture of, 239 
in glaucoma, 304 
wounds of, 180, 186, 189 
Sclerotico-cliorioditis, posterior, 
224 

Sclerotomy, 305, 430 
for glaucoma, 430 
Scopilamine, 521 

Scotoma, central, in amblyopia, 
273 

scintillating, 467 

Scrofula, a cause of blepharitis, 86 
Scrofulous sclerotitis, 168 
Scurvy, 460 
night-blindness in, 280 
Semilunar fold, papilloma of, 311 
Septicaemia, 454 

in dacryo-adenitis, 94 
Sexual disorders, asthenopia in, 
280 

Shades, 527 
Shadow-test, 75 
concave mirror in, 76, 78 
determination of astigmatism 
by, 76, 78 

hypermetropia by, 76, 78 
myopia by, 76, 78 
refraction by, 76 
plane mirror in, 76, 79, 82 
Sight, loss of, after hemorrhage, 
449 

temporary loss of, 461 
Silver, nitrate of, 513 
Sinuses, nasal, diseases of, 476 


Skiascopy {see Shadow-test). 
Smallpox, 450 

of conjunctiva, 450 
iritis after, 450 
keratitis after, 450 
in stricture of nasal duct, 97 
Snellen type, 529 
Snow-blindness, 124 
Soda, preparation of, 516 
Spinal cord, diseases of, optic 
atrophy in, 265 
Squint {see Strabismus). 

paralytic, vertigo in, 384 
Staphyloma, ciliary, 169, 176 
posterior, 224, 334 
Stellway’s sign, 475 
Stillicidium lacrymarum, 94 
Stomach, hemorrhage from, optic 
neuritis in, 261 
Strabismus, 365 
advancement agent in, 375 
after operation, 376 
alternating, 368 
amblyopia in, 269 
concomitant, 369 
convergent, 368, 373 
after diphtheria, 451 
in hypermetropia, 348 
treatment of, 374 
diplopia in, 368 
divergent, 366, 375 
in myopia, 332 
prisms in, 375 
treatment of, 375 
from disease, 376 
images in, 365, 368 
in motor disorders, 471 
Maddox rod in, 375 
measurement of, 369 
corneal reflex in, 371 
perimeter in, 371 
paralytic, 369, 379, 383 
periodic, 369 
primary, 369, 384 
secondary, 369, 384 
tenotomy in, 374 
treatment of, caruncle after, 
376 

visual axis in, 365 
Strumous diathesis, 466 
Stye, 87 

symptoms of, 87 
treatment of, 88 
Subconjunctival injections, 524 
Subvaginal space, 255 
Supraduction, measurement of, 53 



INDEX. 


559 


Suprarenal capsules, 524 
Sycosis tarsi (see Blepharitis). 
Symblepliaron, 184 
operations for, 405 
Harlan’s, 405 
Snellen’s, 405 

Sympathetic inflammation, 176 
prognosis in, 179 
treatment of, 177 
irritation, 173, 278 
symptoms of, 175 
ophthalmia, 173 
ciliary body in, 173 
paralysis of cervical, 474 
Sympathizing eye, 173 
Symptoms of albuminuric reti¬ 
nitis, 244 
astigmatism, 354 
blepharitis, 85 
cataract, 197 
chalazion, 88 
glaucoma, 292, 294 
hypermetropia, 347 
inflammation of cornea, 125 
iritis, 153 

lachrymal abscess, 97 
myopia, 331 
panophthalmitis, 172 
stye, 87 

sympathetic irritation, 175 
Synchysis in diseases of vitreous, 
287 

Syndectomy, 120 
Synechise, atropine in, 1G1 
in ophthalmitis, 176 
posterior, 153 

as a cause of relapses in iritis, 
158 

total, 155, 157 
in serous cyclitis, 170 
Syphilis, acquired, 447 
of brain, 448 
of ciliary body, 448 
of conjunctiva, 447 
of cornea, 448 
in dacryo-adenitis, 94 
in diseases of vitreous, 289 
inherited, 449 
of iris, 447 
in iritis, 158 
in keratitis, 147 
of lid, 311, 447 
in ocular paralysis, 389, 448 
optic neuritis in, 260, 448 
in retinitis, 240, 448 
in scleritis, 167 


Syphilis in stricture of nasal duct, 
96 

in tumors of orbit, 328 
Syphilitic choroiditis, 218, 448 
Syringing, lachrymal, 410 

T. 

Teeth, caries of, in cellulitis of 
orbit, 322 

in inherited syphilis, 476 
in rickets, 194, 476 
in tumors of orbit, 326 
in zonular cataract, 194 
Tendo oculi, 325 
Tenotomy, 411 
in myopia, 342 
in strabismus, 374 
Tension of eyeball, 46 
Test types, 529 

Thrombosis of orbital veins, 226 
Tinea tarsi (see Blepharitis). 
Trachoma (see Granular conjunc¬ 
tivitis). 

operations for, 405 
Traumatic cataract, 210 
Ti'eatment of abrasions of cornea, 
184 

asthenopia, 279 
blepharitis, 87 
cataract, 203 
chalazion, 89 
choroiditis, 223 

conjunctivitis, diphtheritic, 111 
epidemic, 108 
granular, 116 
purulent, 103 
dacryo-adenitis, 94 
detachment of retina, 239 
glaucoma, 303 

gunshot injuries of eyeball, 186 
hypermetropia, 348 
hypopyon,140 
inflammation of cornea, 137 
injuries of eyeball without rup¬ 
ture, 183 

interstitial inflammation of cor¬ 
nea, 146 
iritis, 161 

lachrymal abscess, 97 
misplaced cilia, 121 
mucocele, 98 
night-blindness, 281 
obstruction of nasal duct, 98 
ocular paralysis, 390 
opacities of cornea, 126 


»v- 




5G0 


INDEX. 


Treatment, pannus, 119 
penetrating wounds of eyeball, 
186 

presbyopia, 363 
prolapse of iris, 190 
rodent cancer of eyelids, 92 
rupture of eyeball, 180 
scleritis, 168 
sclero-keratitis, 169 
serous cyclitis, 172 
strabismus, 374, 375 
stye, 88 

sympathetic inflammation, 177 
traumatic cataract, 210 
tuberculosis of conjunctiva, 
311 

Tremulous iris, 181 
Trial frame, employment of, 35 
Trichiasis, 119 
congenital, 93 
operations for, 395 
Tropacocaine, 521 
Tubercle of conjunctiva, 92 
of iris, 320 
Tuberculosis, 462 
of conjunctiva, 311 
optic neuritis in, 260 
Tumors and growths of conjunc¬ 
tiva, 311 et seq. 
intra-ocular, 315 
cataract after, 197 
detection of, 60 
secondary glaucoma after, 
309 

Typhus fever, 450 

IT. 

Ulcers of eyelids, 90 
Uterus, disease of, asthenopia in, 
280 

Uveal tract, inflammation of, 173 

V. 

Vertigo in paralytic squint, 384 
Vision (see Sight), 
acuteness of, 48 
standards of, 48, 49 
tests for, 48, 479, 487 
colored, 281 
field of, 54 

influence of pupil on, 32 
optical convictions of clear, 32 
Visual axis, 31 

field, colors in, 285 


Visual field in glaucoma, 292, 295 
in hysteria, 277 
Vitreous, blood in, 289 
cysticercus in, 467 
degeneration of, 286 
diseases of, 286 
. cataract after, 197 
causes of, 289, 290 
cholesterin in, 288 
choroid in, 286 
choroido-retinitis in, 288 
constipation in, 289 
cyclitis in, 289 
detachment of retina in, 28y 
epistaxis in, 289 
gout in, 289 
hemorrhage in, 289 
iritis in, 160 

muscse volitantes in, 281 
myopia in, 289 
ophthalmoscope in, 288 
penetrating wounds in, 289 
sympathetic ophthalmitis in, 
289 

synchysis in, 287, 288 
syphilis in, 289 
examination of, 286 
exudation into, in choroiditis, 

226 

foreign bodies in, 188, 289 
hemorrhage into, 180, 182 
in myopia, 337 
opacities of, 286 
detection of, 60 
in panophthalmitis, 172 
parasites in, 289 
pus in, 289 

in serous cyclitis, 170 

w. 

Weeks, bacillus of, 108 
Wernicke sign, 276 
Whooping-cough, 452 

X. 

Xanthelasma palpebrarum, 90 
Xerotic patches, 135 

Z. 

Zinc, preparation of, 515 
Zone, ciliary, 165 
Zonular cataract, 194, 200 5 



CATALOGUE OF PUBLICATIONS OF 

LEA BROTHERS & COMPANY, 

706, 708 & 710 Sansom St., Philadelphia. 

Ill Fifth Ave. (Cor. 18th St.), New York. 

__ The books in the annexed list will be sent by mail, post-paid, to any Post-Office in the 
United States, on receipt of the printed prices. 


INDEX. 

ANATOMY^ Gray, p. 11 ; Treves, 30 ; Gerrish, 11; Brockway, 4. 
DICTIONARIES. Dungli8on, p. 8; Duane, 8 ; National, 4 
PHYSICS. Draper, p. 8 ; Robertson, 24 ; Martin & Rockwell, 20. 
PHYSIOLOGY. Foster, p. 10; Chapman, 5; Schofield, 25; Collins 
& Rockwell, 6. [Luff, 19 ; Remsen, 24. 

CHEMISTRY. Simon, p. 26 ; Attfield, 3 ; Martin & Rockwell, 20; 
PHARMACY. Caspari, p. 5. [Bruce, 4 : Schleif, 25. 

MATERIA MEDICA. Culbretb, p. 6 ; Maisch, 19 ; Farquharson, 9 ; 
DISPENSATORY. National, p. 21. 

THERAPEUTICS. Hare, p. 13 ; Fothergill, 10 ; Whitla, 31 ; Hayem 
& Hare, 14 ; Bruce, 4 ; Schleif, 25 ; Cushny, 6. 

PRACTICE. Flint, p. 9 ; Loomis & Thompson, 19 ; Malsbary, 20. 
DIAGNOSIS. Musser, p. 21; Hare, 12; Simon, 25; Herrick, 15; Hutchi¬ 
son & Rainey, 16 ; Collins, 6. 

CLIMATOLOGY. Solly, p. 26 ; Hayem & Hare, 14. 

NERVOUS DISEASES. Dercum, p. 7 ; Gray, 11 ; Potts, 23. 
MENTAL DISEASES. Clouston, p. 5; Savage, 24 ; Folsom, 10. 
BACTERIOLOGY. Abbott, p. 2; Vaughan & Novy, 30; Senn’s 
(Surgical), 25. Park, 22 ; Coates, 6. [Vale, 21. 

HISTOLOGY. Klein, p. 17 ; Schafer’s, 25 ; Dunham, 8 ; Nichols & 
PATHOLOGY. Green, p. 12; Gibbes, 10; Coats, 6; Nichols & Vale, 21 
SURGERY. Park, p. 22; Dennis, 7; Roberts, 24; Ashhurst, 3; Treves, 29; 

Cheyne & Burghard, 5 ; Gallaudet, 10. 

SURGERY — OPERATIVE. Stimson, p. 27 ; Smith, 26 ; Treves, 29. 
SURGERY — ORTHOPEDIC. Young, p. 31 ; Gibney, 10. 
SURGERY — MINOR. Wharton, p. 30. [BalleDger & 

FRACTURES and DISLOCATIONS. Stimson, p. 27. [Wippern, 3. 
OPHTHALMOLOGY. Norris & Oliver, p. 21; Nettleship, 21; Juler, 17; 
OTOLOGY. Politzer, p. 23; Burnett, 5; Field, 9; Bacon, 4. 
LARYNGOLOGY and RHINOLOGY. Coakley, p. 6 ; 
DENTISTRY. Essig (Prosthetic), p. 9 ; Kirk (Operative), 17 ; Ameri¬ 
can System. 2 ; Coleman, 6; Burchard 4. 

URINARY DISEASES. Roberts, p. 24 ; Black, 4. 

VENEREAL DISEASES. Taylor, p. 28 ; Hayden, 14 ; Cornil, 6 ; 
SEXUAL DISORDERS. Fuller, p. 10 ; Taylor, 29. [Likes, 19. 
DERMATOLOGY. Hyde, p. 16 ; Jackson, 16 ; Pye-Smith, 24 ; Mor¬ 
ris, 20; Jamieson, 16; Hardaway, 12 ; Grindon, 12. 
GYNECOLOGY. American System, p. 3 ; Thomas & Mund6, 29 
Emmet, 9 ; Davenport, 7 ; May, 20 ; Dudley, 8 ; Crockett, 6. 
OBSTETRICS. American System, p. 3 ; Davis, 7 ; Parvin, 22 ; Play¬ 
fair, 23 ; King, 17 ; Jewett, 17 ; Evans, 9. 

PEDIATRICS. Smith, p 26 ; Thomson, 29 ; Williams, 31 ; Tuttle, 30. 
HYGIENE. Egbert, p. 9 ; Richardson, 24 ; Coates, 6. 

MEDICAL JURISPRUDENCE. Taylor, p. 28. 

QUIZ SERIES, POCKET TEXT-BOOKS and MANUALS. 

Pp. 18, 25 and 27. 

1.15.00. 









2 Lea Brothers & Co., Philadelphia and New York 


ABBOTT (A. C.). PRINCIPLES OF BACTERIOLOGY: a Practical 
Manual for Students and Physicians. New (5th) edition thoroughly 
revised and greatly enlarged. In one handsome 12mo. vol. of 585 pages, 
with 109 engrav., of which 26 are colored. Just ready. Cloth, $2.75, net. 


cessfully. To those who require a 
condensed yet nevertheless complete 
work upon Bacteriology we most 
cordially recommend it.— The Thera¬ 
peutic Gazette. 


One of its most attractive charac¬ 
teristics is that the directions are so 
clearly given that anyone with a 
moderate amount of laboratory train¬ 
ing can, with a little care as to 
detail, make his experiments suc- 

AMERICAN SYSTEM OF PRACTICAL MEDICINE. A SYS¬ 
TEM OF PRACTICAL MEDICINE. In contributions by Various 
American Authors. Edited by Alfred L. Loomis, M.D., LL.D., 
and W. Gilman Thompson, M. D. In four very handsome octavo 
volumes of about 900 pages each, fully illustrated. Complete work 
now ready. Per volume, cloth, $5; leather, $6; half Morocco, $7. 
For sale by subscription only. Prospectus free on application. 


Every chapter is a masterpiece of 
completeness, and is particularly ex¬ 
cellent in regard to treatment, many 
original prescriptions, formulae, 
charts and tables being given for the 
guidance of the practitioner. 

“The American System of Medi¬ 


cine” is a work of which every 
American physician may reasonably 
feel proud, and in which every prac¬ 
titioner will find a safe and trust¬ 
worthy counsellor in the daily re¬ 
sponsibilities of practice.— The Ohio 
Medical Journal. 


AMERICAN SYSTEM OF DENTISTRY. In treatises by various 

authors. Edited by Wilbur F. Litch, M.D., D.D.S. In three very 
handsome super-royal octavo volumes, containing about 3200 pages, 
with 1873 illustrations and many full-page plates. Per vol., cloth, 
$6; leather, $7 ; half Morocco, $8. For sale by subscription only. Pros¬ 
pectus free on application to the Publishers. 


AMERICAN TEXT-BOOKS OF DENTISTRY. In Contribu¬ 
tions by Eminent American Authorities. In two very handsome 
octavo volumes, richly illustrated : 

PROSTHETIC DENTISTRY. Edited by Charles J. Essig, M.D., 
D.D.S., Professor of Mechanical Dentistry and Metallurgy, Department 
of Dentistry, University of Pennsylvania, Philadelphia. 760 pages, 
983 engravings. Cloth, $6; leather, $7. Net. 

No more thorough production will i It is up to date in every particular, 
be found either in this country or in It is a practical course on prosthetics 
any country where dentistry is un- which any student can take up dur- 


derstood as a part of civilization.— 
The International Dental Journal. 


ing or after college.— Dominion Den¬ 
tal Journal. 


OPERATIVE DENTISTRY. Edited by Edward C. Kirk, D.D.S., 
Professor of Clinical Dentistry, Department of Dentistry, University 
of Pennsylvania. 699 pages, 751 engravings. Cloth, $5.50; leather, 
$6.50. Net. Just ready. 


Written by a number of practi¬ 
tioners as well known at the chair 
as in journalistic literature, many of 
them teachers of eminence in our 
colleges. It should be included in 
the list of text-books set down as 
most useful to the college student.— 
The Dental News. 


It is replete in every particular 
and treats the subject in a progressive 
manner. It is a book that every 
progressive dentist should possess, 
and we can heartily recommend it 
to the profession.— The Ohio Dental 
Journal. 






Lea Brothers A Co., Philadelphia and New York. 3 


AMERICAN SYSTEMS OF GYNECOLOGY AND OBSTET¬ 
RICS. In treatises by the most eminent American specialists. Gyne¬ 
cology edited by Matthew D. Mann, A. M., M. D., and Obstetrics 
edited by Barton C. Hirst, M. D. In four large octavo volumes 
comprising 3612 pages, with 1092 engravings, and 8 colored plates. Per 
volume, cloth, $5 ; leather, $6; half Russia, $7. For sale by subscrip¬ 
tion only. Prospectus free on application to the Publishers. 


AMERICAN TEXT-BOOK OF ANATOMY. See Gerrish , page 11. 

ALLEN (HARRISON). A SYSTEM OF HUMAN ANATOMY- 
WITH AN INTRODUCTORY SECTION ON HISTOLOGY, by 
E. O. Shakespeare, M.D. Comprising 813 double-columned quarto 
pages, with 380 engravings on stone, 109 plates, and 241 wood cuts 
in the text. In six sections, each in a portfolio. Price per section, $3.50. 
Also, bound in one volume, cloth, $23. Sold by subscription only. 


A PRACTICE OF OBSTETRICS BY AMERICAN AU¬ 
THORS. See Jewett , page 17. 

A TREATISE ON SURGERY BY AMERICAN AUTHORS. 

FOR STUDENTS AND PRACTITIONERS OF SURGERY AND 
MEDICINE. Edited by Roswell Park, M.D. See page 22. 

ASHHURST (JOHN, JR.). THE PRINCIPLES AND PRACTICE 
OF SURGERY. For the use of Students and Practitioners. Sixth 
and revised edition. In one large and handsome octavo volume of 
1161 pages, with 656 engravings. Cloth, $6 ; leather, $7. 


As a masterly epitome of what has 
been said and done in surgery, as a 
succinct and logical statement of the 
principles of the subject, as a model 


text-book, we do not know its equal. 
It is the best single text-book of 
surgery that we have yet seen in this 
country.— New York Post-Graduate. 


A SYSTEM OF PRACTICAL MEDICINE BY AMERICAN 
AUTHORS. Edited by William Pepper, M.D., LL. D. In five 
large octavo volumes, containing 5573 pages and 198 illustrations. Price 
per volume, cloth, $5 ; leather $6 ; half Russia, $7. Sold by subscrip¬ 
tion only. Prospectus free on application to the Publishers. 


ATTFEELD (JOHN). CHEMISTRY; GENERAL, MEDICAL AND 
PHARMACEUTICAL. New (16th) edition, specially revised by the 
Author for America. In one handsome 12mo. volume of 784 pages, 
with 88 illustrations. Cloth, $2.50, net. 

It is replete with the latest inform- been adopted, bringing the work into 
ation, and considers the chemistry of close touch with the latest United 
every substance recognized officially States Pharmacopoeia , of which it is 
or in general practice. The modern a worthy companion.— The Pittsburg 
scientific chemical nomenclature has Medical Review. 


BALLENGER (W. L.) AND WIPPERN (A. G.). Shortly. A 

POCKET TEXT-BOOK OF DISEASES OF THE EYE, EAR, 
NOSE AND THROAT. In one handsome 12mo. volume of about 
400 pages, with many illustrations. Lea's Series of Pocket Text-books, 
edited by Bern B. Gallaudet, M. D. See p. 18. 

BARNES (ROBERT AND FANCOURT). A SYSTEM OF OB 
STETRIC MEDICINE AND SURGERY. Octavo, 872 pages, with 
231 illus. Cloth, $5 : leather, $6. 







4 Lea Brothers & Co., Philadelphia and New York. 


BACON (GORHAM). ON THE EAR. One 12mo. volume, 400 pages, 
109 engravings and a colored plate. Cloth, net, $2.00. Just ready. 

It is thebest manual upon otology, dents of medicine— Cleveland Jour- 
An intensely practical book for stu- nal of Medicine. 


BARTHOLOW (ROBERTS). CHOLERA; ITS CAUSATION, PRE¬ 
VENTION AND TREATMENT. In one 12mo. volume of 127 pages, 
with 9 illustrations. Cloth, $1.25. 

BARTHOLOW (ROBERTS). MEDICAL ELECTRICITY. A 
PRACTICAL TREATISE ON THE APPLICATIONS OF ELEC¬ 
TRICITY TO MEDICINE AND SURGERY. Third edition. In 
one octavo volume of 308 pages, with 110 illustrations. 


BILLINGS (JOHN S.). THE NATIONAL MEDICAL DICTIONARY. 
Including in one alphabet English, French, German, Italian and 
Latin Technical Terms used in Medicine and the Collateral Sciences. 
In two very handsome imperial octavo volumes containing 1574 
pages and two colored plates. Per volume, cloth, $6; leather, $7; 
naif Morocco, $8.50. For sale by subscription only. Specimen pages 
on application to the publishers. 


BLACK (D. CAMPBELL). THE URINE IN HEALTH AND 
DISEASE, AND URINARY ANALYSIS, PHYSIOLOGICALLY 
AND PATHOLOGICALLY CONSIDERED. In one 12mo. volume 
of 256 pages, with 73 engravings. Cloth, $2.75. 


A concise, yet complete manual, 
treating of the subject from a prac¬ 
tical and clinical standpoint.— The 
Ohio Medical Journal. 


Concise, practical, clinical, well 
illustrated and well printed.— Mary¬ 
land Medical Journal. 


BLOXAM (C. L.). CHEMISTRY, INORGANIC AND ORGANIC. 
With Experiments. New American from the fifth London edition. 
In one handsome octavo volume of 727 pages, with 292 illustrations. 
Cloth, $2 ; leather, $3. 

BROCKWAY (F. J.). A POCKET TEXT-BOOK OF ANATOMY. 
In one handsome 12mo. volume of about 400 pages, with many illus¬ 
trations. Shortly. Lea's Series of Pocket Text-books, edited by Bern 
B. Gallaudet, M. D. See page* 18. 

BRUCE (J. MITCHELL). MATERIA MEDICA AND THERA¬ 
PEUTICS. New (6th) edition. In one 12mo. volume of 600 pages. 
Just ready. Cloth, $1.50, net. See Student's Series of Manuals, 
page, 27. 

- PRINCIPLES OF TREATMENT. In one octavo volume. Pre¬ 
paring. 

BRYANT (THOMAS). THE PRACTICE OF SURGERY. Fourth 
American from the fourth English edition. In one imperial octavo vol. 
of 1040 pages, with 727 illustrations. Cloth, $6.50; leather, $7.50. 

BURCHARD (HENRY H.). DENTAL PATHOLOGY AND THER¬ 
APEUTICS. Handsome octavo, 575 pages, with 400 illustrations. 
Cloth, net, $5.00; leather, net, $6.00. 






Lea Bbothers & Co., Philadelphia and New Yoek 


5 


BURNETT (CHARLES H.p THE EAR: ITS ANATOMY, PHYSI¬ 
OLOGY AND DISEASES. A Practical Treatise for the Use of 
Students and Practitioners. Second edition. In one 8vo. volume of 
580 pages, with 107 illustrations. Cloth, $4; leather, $5. 

CARTER (R. BRUDENELL) AND FROST (W. ADAMS). OPH¬ 
THALMIC SURGERY. In one pocket-size 12mo. volume of 559 
pages, with 91 engravings and one plate. Cloth, $2.25. See Series of 
Clinical Manuals , page 25. 


CASPARI (CHARLES JR.). A TREATISE ON PHARMACY. 
For Students and Pharmacists. In one handsome octavo volume of 
680 pages, with 288 illustrations. Cloth, $4.50. 


The author’s duties as Professor 
of Theory and Practice of Pharmacy 
in the Maryland College of Phar¬ 
macy, and his contact with students 
made him aware of their exact 
wants in the matter of a manual. 

His work is admirable, and the 

CHAPMAN (HENRY C.). A TREATISE ON HUMAN PHYSI¬ 
OLOGY. New (2d) edition. In one octavo volume of 921 pages, 
with 595 illustrations. Just ready. Cloth, $4.25 ; leather, $5.25, net. 


student who cannot understand must 
be dull indeed. The book is full of 
new, clean, sharp illustrations,which 
tell the story frequently at a glance. 
The index is full and accurate.— 
National Druggist. 


In every respect the work fulfils 
its promise, whether as a complete 
treatise for the student or as an ad¬ 


mirable work of reference for the 
physician .—North Carolina Medical 
Journal. 


CHARLES (T. CRANSTOUN). THE ELEMENTS OF PHYSIO¬ 
LOGICAL AND PATHOLOGICAL CHEMISTRY. Octavo, 451 
pages, with 38 engravings and 1 colored plate. Cloth, $3.50. 


CHEYNE (W. WATSON). THE TREATMENT OF WOUNDS, 
ULCERS AND ABSCESSES. In one 12mo. volume of 207 pages. 


Cloth, $1.25. 

One will be surprised at the 
amount of practical and useful in¬ 
formation it contains; information 
that the practitioner is likely to 


need at any moment. The sections 
devoted to ulcers and abscesses are 
indispensable to any physician.— 
The Charlotte Medical Journal. 


CHEYNE (W. W.) AND BURGHARD (F. F.). SURGICAL 
TREATMENT. In six octavo volumes, illustrated. Now ready. 
Volume 1, 299 pages and 66 engravings. Cloth, $3.00 net. Volume 2, 
382 pages, 141 engravings. Cloth, $4.00 net. 

CLARKE (W. B.) AND LOCKWOOD (C. B.). THE DISSECTOR’S 
MANUAL. In one 12mo. volume of 396 pages, with 49 engravings. 
Cloth, $1.50. See Students’ Series of Manuals, page 27. 

CLELAND (JOHN). A DIRECTORY FOR THE DISSECTION OF 
THE HUMAN BODY. In one 12mo. vol. of 178 pages. Cloth, $1.25. 

CLINICAL MANUALS. See Series of Clinical Manuals, page 25. 


CLOUSTON (THOMAS S.). CLINICAL LECTURES ON MENTAL 
DISEASES. New (5th) edition. In one octavo volume of 750 pages, 
with 19 colored plates. Cloth, $4.25, net. Just ready. 
^©"Folsom’s Abstract of Laws of U. S. on Custody of Insane, octavo, 
$1.50, is sold in conjunction with Clouston on Mental Diseases for 
$5.00, net, for the two works. 









6 Lea Brothers & Co., Philadelphia i and New York. 


CLOWES (FRANK). AN ELEMENTARY TREATISE ON PRACTI¬ 
CAL CHEMISTRY AND QUALITATIVE INORGANIC ANALY¬ 
SIS. From the fourth English edition. In one handsome 12mo. 
volume of 387 pages, with 55 engravings. Cloth, $2.50. 

COAKLEY (CORNELIUS G.). THE DIAGNOSIS AND TREAT¬ 
MENT OF DISEASES OF THE NOSE, THROAT, NASO¬ 
PHARYNX AND TRACHEA. In one 12mo. volume of 526 pages 
with 92 engravings and 2 colored plates. Just ready. Cloth, $2.75. net. 

COATES (W. E„ JR.). A POCKET TEXT-BOOK OF BACTE¬ 
RIOLOGY AND HYGIENE. In one handsome 12mo. volume of 
about 350 pages, with many illustrations. Shortly. Leas Series of 
Pocket Text-books , edited by Bern B. Gallaudet, M. D. See 
page 18. 

COATS (JOSEPH). A TREATISE ON PATHOLOGY. In one vol. 
of 829 pages, with 339 engravings. Cloth, $5.50; leather, $6.50. 

COLEMAN (ALFRED). A MANUAL OF DENTAL SURGERY 
AND PATHOLOGY. With Notes and Additions to adapt it to Amer¬ 
ican Practice. By Thos. C. Stellwagen, M.A., M.D., D.D.S. In one 
handsome octavo vol. of 412 pages, with 331 engravings. Cloth, $3.25. 

COLLINS (C. P.). A POCKET TEXT-BOOK OF MEDICAL 
DIAGNOSIS. In one handsome 12mo. volume of about 350 pages, 
with many illustrations. Shortly. Lea’s Series of Pocket Text-books, 
edited by Bern B. Gallaudet, M. D. See page 18. 

COLLINS (H. D.) AND ROCKWELL (W. H.). A POCKET 

TEXT-BOOK OF PHYSIOLOGY. 12mo. of 316 pages, with 153 
illustrations. Just ready. Cloth, $1.50; flexible red leather, $2.00, 
net. Lea’s Series of Pocket Text-books, edited by Bern B. Gallau¬ 
det, M. D. See page 18. 

CONDIE (D. FRANCIS). A PRACTICAL TREATISE ON THE DIS¬ 
EASES OF CHILDREN. Sixth edition, revised and enlarged. In 
one large 8vo. volume of 719 pages. Cloth, $5.25; leather, $6.25. 

CORNIL (V.). SYPHILIS: ITS MORBID ANATOMY, DIAGNO¬ 
SIS AND TREATMENT. Translated, with Notes and Additions, by 
J. Henry C. Simes, M.D. and J. William White, M.D. In one 
8vo. volume of 461 pages, with 84 illustrations. Cloth, $3.75. 

CROCKETT (M. A.). A POCKET TEXT-BOOK OF DISEASES 
OF WOMEN. In one handsome 12mo. volume of about 350 pages, 
with many illustrations. Shortly. Lea’s Series of Pocket Text-books, 
edited by Bern B. Gallaudet, M. D. See page 18. 

CROOK (JAMES K.) ON MINERAL WATERS OF THE 
UNITED STATES. Octavo, 575 pages. Just ready. Cloth, $3.50, net. 

CULBRETH (DAVID M. R.). MATERIA MEDICA AND PHAR¬ 
MACOLOGY. In one handsome octavo volume of 812 pages, with 
445 illustrations. Cloth, $4.75. 

CUSHNY (ARTHUR R.). TEXT-BOOK OF PHARMACOLOGY. 
Handsome 8vo., 728 pages, with 47 illus. Just ready. Cloth, $3.75, net. 






Lea Brothers & Co., Philadelphia and New York. 


7 


DALTON (JOHN C.). A TREATISE ON HUMAN PHYSIOLOGY. 
Seventh edition. Octavo, 722 pages, with 252 engravings. Cloth, 
$5; leather, $6. 8 

-DOCTRINES OF THE CIRCULATION OF THE BLOOD. In 

one handsome 12mo. volume of 293 pages. Cloth, $2. 

DAVENPORT (F. H.). DISEASES OF WOMEN. A Manual ot 
Gynecology. For the use of Students and Practitioners. New 
(3d) edition. In one handsome 12mo. volume of 387 pages, with 150 
illustrations. Cloth, $1.75, net. Just ready. 

DAVIS (EDWARD P.). A TREATISE ON OBSTETRICS. FOR 
STUDENTS AND PRACTITIONERS. In one very handsome 
octavo volume of 546 pages, with 217 engravings and 30 full-page 
plates in colors and monochrome. Cloth, $5 ; leather, $6. 

From a practical standpoint the thoroughly scientific and brilliant 

work is all that could be desired. A treatise on obstetrics. —Med. News. 

DAVIS (F. H.). LECTURES ON CLINICAL MEDICINE. Second 
edition. In one 12mo. volume of 287 pages. Cloth, $1.75. 


DE LA BECHE’S GEOLOGICAL OBSERVER. In one large octavo 
volume of 700 pages, with 300 engravings. Cloth, $4. 


DENNIS (FREDERIC S.) AND BILLINGS (JOHN S.). A SYS¬ 
TEM OF SURGERY. In contributions by American Authors. 
Complete work in four very handsome octavo volumes, containing 
3652 pages, with 1585 engravings and 45 full-page plates in colors 
and monochrome. Per volume, cloth, $6.00; leather, $7.00; half 
Morocco, gilt back and top, $8.50. For sale by subscription only. 
Full prospectus free on application to the publishers. 


It is worthy of the position which 
surgery has attained in the great 
Republic whence it comes. — The 
London Lancet. 

It may be fairly said to represent 
the most advanced condition of 


American surgery and is thoroughly 
practical.— Annals of Surgery. 

No work in English can be con¬ 
sidered as the rival of this.— The 
American Journal of the Medical 
Sciences. 


DERCUM (FRANCIS X., EDITOR). A TEXT-BOOK ON 
NERVOUS DISEASES. By American Authors. In one handsome 
octavo volume of 1054 pages, with 341 engravings and 7 colored 
plates. Cloth, $6.00 ; leather, $7.00. Net. 


Representing the actual status of 
our knowledge of its subjects, aud 
the latest and most fully up-to-date 
of any of its class.-— Jour, of Amer¬ 
ican Med. Association. 

The most thoroughly up-to-date 
treatise that we have on this subject. 
—American Journal of Insanity. 


The work is representative of the 
best methods of teaching, as devel¬ 
oped in the leading medical colleges 
of this country.— Alienist and Neu¬ 
rologist. 

The best text-book in any lan¬ 
guage.— The Medical Fortnightly. 


DE SCHWEINITZ (GEORGE E.). THE TOXIC AMBLYOPIAS. 
Their Classification, History, Symptoms, Pathology and Treatment. 
Very handsome octavo, 240 pages, 46 engravings, and 9 full-page 
plates in colors. Limited edition, de luxe binding, $4. Net. 





8 Lea Brothers & Co., Philadelphia and New York. 


DRAPER (JOHN C.). MEDICAL PHYSICS. A Text-book for Stu¬ 
dents and Practitioners of Medicine. In one handsome octavo volume 
of 734 pages, with 376 engravings. Cloth, $4. 

DRUITT (ROBERT). THE PRINCIPLES AND PRACTICE OF 
MODERN SURGERY. A new American, from the twelfth London 
edition, edited by Stanley Boyd, F. R. C. S. In one large octavo 
volume of 965 pages, with 373 engravings. Cloth, $4; leather, $5. 

DUANE (ALEXANDER). THE STUDENT’S DICTIONARY OF 
MEDICINE AND THE ALLIED SCIENCES. New edition. Com¬ 
prising the Pronunciation, Derivation and Full Explanation of Medi¬ 
cal Terms, with much Collateral Descriptive Matter. Numerous Tables, 
etc. Square octavo of 658 pages. Cloth, $3.00; half leather, $3.25; 
full sheep, $3.75. Thumb-letter Index, 50 cents extra. 

DUDLEY (E. C.). THE PRINCIPLES AND PRACTICE OF 
GYNECOLOGY. New (2d) edition. Handsome octavo of 717 pages, 
with 453 illustrations in black and colors, and 8 colored plates. Cloth, 
$5.00 , net; leather, $6.00, wet. Just ready. 

The book can be safely recoin- tice of modem gynecology.— Inter - 

mended as a complete and reliable national Medical Magazine. 

exposition of the principles and prac- 

DIJNCAN (J. MATTHEWS). CLINICAL LECTURES ON THE 
DISEASES OF WOMEN. Delivered in St. Bartholomew’s Hospital. 
In one octavo volume of 175 pages. Cloth, $1.50. 


DUNGLISON (ROBLEY). A DICTIONARY OF MEDICAL SCI¬ 
ENCE. Containing a full explanation of the various subjects and 
terms of Anatomy, Physiology ; Medical Chemistry, Pharmacy, Phar¬ 
macology, Therapeutics, Medicine, Hygiene, Dietetics, Pathology, Sur¬ 
gery, Ophthalmology, Otology, Laryngology, Dermatology, Gynecol- 
ogy, Obstetrics, Pediatrics, Medical Jurisprudence, Dentistry, etc., etc. 
By Robley Dunglison, M. D., LL. D., late Professor of Institutes 
of Medicine in the Jefferson Medical College of Philadelphia. Edited 
by Richard J. Dtjnglison, A. M., M. D. Twenty-first edition, thor¬ 
oughly revised and greatly enlarged and improved, with the Pronuncia¬ 
tion, Accentuation and Derivation of the Terms. With Appendix. 
In one magnificent imperial octavo volume of 1225 pages. Cloth, $7 ; 
leather, $8 Thumb-letter Index for quick use, 75 cents extra. 


The most satisfactory and authori- scarcely be measured.— Med. Record. 


Pronunciation is indicated by the 
phonetic system. The definitions are 
unusually clear and concise. The 
book is wholly satisfactory.— Uni¬ 
versity Medical Magazine. 


tative guide to the derivation, defini¬ 
tion and pronunciation of medical 
terms .—The Charlotte Med. Journal. 

Covering the entire field of medi¬ 
cine, surgery and the collateral 
sciences, its range of usefulness can 

DUNHAM (EDWARD K.). MORBID AND NORMAL HIS¬ 
TOLOGY. Octavo, 450 pages,with 363 illustrations. Cloth, $3.25, net. 

The best one-volume text or refer- i of published in America.— Virginia 
ence book on histology that we know I Medical Semi-Monthly. 

EDES (ROBERT T.). TEXT-BOOK OF THERAPEUTICS AND 
MATERIA MEDICA. In one8vo. volume of 544 pages. Cloth, $3.50; 
leather, $4.50. 

EDIS (ARTHUR W.). DISEASES OF WOMEN. A Manual for 
Students and Practitioners. In one handsome 8vo. volume of 576 pages, 
with 148 engravings. Cloth, $3 ; leather, $4. 







Lea Brothers & Co., Philadelphia and New York. 9 


EGBERT (SENECA). A MANUAL OF HYGIENE AND SANI¬ 
TATION. In one 12mo. volume of 359 pages, with 63 illustrations. 
Just ready. Cloth, Net , $2.25. 


It is written in plain language, 
and, while primarily designed for 
physicians, it can be studied with 
profit by any one of ordinary intel¬ 


ligence. The writer has adapted it 
to American conditions, and his 
suggestions are, above all, practical. 
— The New York Medical Journa l. 


ELLIS (GEORGE VINER). DEMONSTRATIONS IN ANATOMY. 
Eighth edition. Octavo, 716 pages, with 249 engravings. Cloth, 
$4.25; leather, $5.25. 

EMMET (THOMAS ADDIS). THE PRINCIPLES AND PRAC¬ 
TICE OF GYNAECOLOGY. Third edition. Octavo, 880 pages, with 
150 original engravings. Cloth, $5; leather, $6. 


ERICHSEN (JOHN E.). THE SCIENCE AND ART OF SUR¬ 
GERY. Eighth edition. In two large octavo volumes containing 
2316 pages, with 984 engravings. Cloth, $9 ; leather, $11. 

ESSIG (CHARLES J.). PROSTHETIC DENTISTRY. S ee American 
Text-Books of Dentistry , page 2. 

EVANS (DAVID J.). A POCKET TEXT-BOOK OF OBSTETRICS. 
In one handsome 12mo. volume of about 300 pages, with many illustra¬ 
tions. Shortly. Lea's Series of Pocket Text-books , edited by Bern B. 
Gallaudet/M. D. See page 18. 


FARQUHARSON (ROBERT). A GUIDE TO THERAPEUTICS. 
Fourth American from fourth English edition, revised by Frank 
Woodbury, M. D. In one 12mo. volume of 581 pages. Cloth, $2.50. 


FIELD (GEORGE P.). A MANUAL OF DISEASES OF THE 
EAR. Fourth edition. In one octavo volume of 391 pages, with 73 
engravings and 21 colored plates. Cloth, $3.75. 


FLINT (AUSTIN). A TREATISE ON THE PRINCIPLES AND 
PRACTICE OF MEDICINE. Seventh edition, thoroughly revised 
by Frederick P. Henry, M. D. In one large 8vo. volume of 1143 
pages, with engravings. Cloth, $5.00; leather, $6.00. 

The work has well earned its lead- | The best of American text-books 

ing place in medical literature.— on Practice.— Amer.Medico-Surgical 

Medical Record. Bulletin. 

-A MANUAL OF AUSCULTATION AND PERCUSSION; or 

the Physical Diagnosis of Diseases of the Lungs and Heart, and of 
Thoracic Aneurism. Fifth edition, revised by James C. Wilson, M. D. 
In one handsome 12mo. volume of 274 pages, with 12 engravings. 

-A PRACTICAL TREATISE ON TIJE DIAGNOSIS AND 

TREATMENT OF DISEASES OF THE HEART. Second edition 
enlarged. In one octavo volume of 550 pages. Cloth, $4. 

-A PRACTICAL TREATISE ON THE PHYSICAL EXPLO¬ 
RATION OF THE CHEST, AND THE DIAGNOSIS OF DIS¬ 
EASES AFFECTING THE RESPIRATORY ORGANS. Second 
and revised edition. In one octavo volume of 591 pages. Cloth, $4.50. 

-MEDICAL ESSAYS. In one 12mo. vol. of 210 pages. Cloth, $1.38. 

_ON PHTHISIS: ITS MORBID ANATOMY, ETIOLOGY,ETC. 

A Series of Clinical Lectures. In one 8vo. volume of 442 pages. 
Cloth, $3.50. 











10 Lea Brothers & Co., Philadelphia and New York 


FOLSOM (C. F.). AN ABSTRACT OF STATUTES OF U. S. 
ON CUSTODY OF THE INSANE. In one 8vo. vol. of 108 pages. 
Cloth, $1.50. With Clouston on Mental Diseases (new edition, see 
page 6) $5.00, net , for the two works. 


FORMULARY, POCKET, see page 32. 


FOSTER (MICHAEL). A TEXT-BOOK OF PHYSIOLOGY. New 
(6th) and revised American from the sixth English edition. In one 
large octavo volume of 923 pages, with 257 illustrations. Cloth, $4.50; 
leather, $5.50. 


Unquestionably the best book that 
can be placed in the student’s hands, 
and as a work of reference for the 
busy physician it can scarcely be 
excelled.— The Phila. Polyclinic. 


This single volume contains all 
that will be necessary in a college 
course, and all that the physician 
will need as well.— Dominion Med. 
Monthly. 


FOTHERGILL (J. MILNER). THE PRACTITIONER’S HAND¬ 
BOOK OF TREATMENT. Third edition. In one handsome octavo 
volume of 664 pages. Cloth, $3.75; leather, $4.75. 


FOWNES (GEORGE). A MANUAL OF ELEMENTARY CHEM¬ 
ISTRY (INORGANIC AND ORGANIC). Twelfth edition. Em¬ 
bodying Watts’ Physical and Inorganic Chemistry. In one royal 
12mo. volume of 1061 pages, with 168 engravings, and 1 colored 
plate. Cloth, $2.75; leather, $3.25. 


FRANKLAND (E.) AND JAPP (F.R.). INORGANIC CHEMISTRY. 

In one handsome octavo volume of 677 pages, with 51 engravings and 
2 plates. Cloth, $3.75 ; leather, $4.75. 


FULLER (EUGENE). DISORDERS OF THE SEXUAL OR¬ 
GANS IN THE MALE. In one verv handsome octavo volume of 


238 pages, with 25 engravings 

It is an interesting work, and one 
which, in view of the large and 
profitable amount of work done in 
this field of late years, is timely and 
well needed.— Medical Fortnightly. 

The book is valuable and instruc- 


and 8 full-page plates. Cloth, $2. 

tive and brings views of sound 
pathology and rational treatment to 
many cases of sexual disturbance 
whose treatment has been too often 
fruitless for good. — Annals of 
Surgery. 


FULLER (HENRY). ON DISEASES OF THE LUNGS AND AIR 
PASSAGES. Their Pathology, Physical Diagnosis, Symptoms and 
Treatment. From second English edition. In one 8vo. volume of 475 
pages. Cloth, $3.50. 

GALLAUDET (BERN B.). A POCKET TEXT-BOOK ON SUR¬ 
GERY. In one handsome 12mo. volume of about 400 pages, with many 
illustrations. Shortly. Lea x s Series of Pocket Text-books, edited by 
Bern B. Gallaudet, M. D. See page 18. 

GANT (FREDERICK JAMES). THE STUDENT’S SURGERY. A 
Multum in Parvo. In one square octavo volume of 845 pages, with 
159 engravings. Cloth, $3.75. 

GIBBES (HENEAGE). PRACTICAL PATHOLOGY AND MORBID 
HISTOLOGY. Octavo, 314 pages, with 60 illustrations. Cloth, $2.75. 

GIBNEY (V. P.). ORTHOPEDIC SURGERY. For the use of Practi¬ 
tioners and Students. In one 8vo. vol. profusely illus. Preparing. 






Lea Brothers & Co., Philadelphia and New York. 11 


GERRISH (FREDERIC H.). A TEXT-BOOK OF ANATOMY. 
By American Authors. Edited by Frederic H. Gerrish, M. D. In one 
imp. octavo volume of 915 pages, with 950 illustrations in black and 
colors. Just ready. Clth,$6.50; flexible waterproof, $7; leath., $7.50, net. 

In this, the first representative treatise on Anatomy produced in America, 
no effort or expense has been spared to unite an authoritative text with the 
most successful anatomical pictures which have yet appeared in the world. 

The editor has secured the co-operation of the professors of anatomy in 
leading medical colleges, and with them has prepared a text conspicuous 
for its simplicity, unity and judicious selection of such anatomical facts as 
bear on physiology, surgery and internal medicine in the most compre¬ 
hensive sense of those terms. The authors have endeavored to make a 
book which shall stand in the place of a living teacher to the student, and 
which shall be of actual service to the practitioner in his clinical work, 
emphasizing the most important subjects, clarifying obscurities, helping 
most in the parts most difficult to learn, and illustrating everything by all 
available methods. 


GOULD (A. PEARCE). SURGICAL DIAGNOSIS. In one 12mo. 
vol. of 589 pages. Cloth, $2. See Student's Series of Manuals, p. 27. 

GRAY (HENRY). ANATOMY, DESCRIPTIVE AND SURGICAL. 
New and thoroughly revised American edition, much enlarged in text, 
and in engravings in black and colors. In one imperial octavo volume 
of 1239 pages, with 772 large and elaborate engravings on wood. Price 
of edition with illustrations in colors : cloth, $7; leather, $8. Price 
of edition with illustrations in black: cloth, $6 ; leather, $7. 


This is the best single volume 
upon Anatomy in the English 
language.— University Medical Mag¬ 
azine. 

Gray's Anatomy affords the student 
more satisfaction than any other 
treatise with which we are familiar. 
—Buffalo Med. Journal. 

The most largely used anatomical 
text-book published in the English 
language.— Annals of Surgery. 

Particular stress is laid upon the 
practical side of anatomical teach¬ 


ing, and especially the Surgical 
Anatomy. —Chicago Med. Recorder. 

Holds first place in the esteem of 
both teachers and students.— I'he 
Brooklyn Medical Journal. 

The foremost of all medical text¬ 
books.— Medical Fortnightly. 

Gray's Anatomy should be the 
first work which a medical student 
should purchase, nor should he be 
without a copy throughout his pro¬ 
fessional career. —Pittsburg Medical 
Review. 


GRAY (LANDON CARTER). A TREATISE ON NERVOUS AND 
MENTAL DISEASES. For Students and Practitioners of Medicine. 
New (2d) edition. In one handsome octavo volume of 728 pages, with 
172 engravings and 3 colored plates. Cloth, $4.75; leather, $5.75. 


An up-to-date text-book upon 
nervous and mental diseases com¬ 
bined. A well-written, terse, ex¬ 
plicit, and authoritative volume 
treating of both subjects is a step in 
the direction of popular demand.— 
The Chicago Clinical Review. 

The descriptions of the various 


diseases are accurate and the symp¬ 
toms and differential diagnosis are 
set before the student in such a way 
as to be readily comprehended. The 
author’s long experience renders his 
views on therapeutics of great value. 
— The Journal of Nervous and Men¬ 
tal Disease. 





12 Lea Brothers & Co., Philadelphia and New York 


GREEN (T. HENRY). AN INTRODUCTION TO PATHOLOGY 
AND MORBID ANATOMY. New (8th) American from the eighth 
London edition. In one handsome octavo volume of 582 pages, with 
216 engravings and a colored plate. Cloth, $2.50, net. Just ready. 


A work that is the text-book of 
probably four-fifths of all the stu¬ 
dents of pathology in the United 
States and Great Britain. —The 
American Practitioner and News. 

It is fully up-to-date in the record 
of fact, and so profusely illustrated 


as to give to each detail of text 
sufficient explanation. The work is 
an essential to the practitioner— 
whether as surgeon or physician. It 
is the best of up-to-date text-books. 
— Virginia Med. Monthly. 


GREENE (WILLIAM H.). A MANUAL OF MEDICAL CHEM¬ 
ISTRY. For the Use of Students. Based upon Bowman’s Medical 
Chemistry. In one 12mo. vol. of 310 pages, with 74 illus. Cloth, $1.75. 


GROSS (SAMUEL D.). A PRACTICAL TREATISE ON THE DIS¬ 
EASES, INJURIES AND MALFORMATIONS OF THE URINARY 
BLADDER, THE PROSTATE GLAND AND THE URETHRA. 
Third edition. Octavo, 574 pages, with 170 illustrations Cloth, $4.50. 

GRINDON (JOSEPH). A POCKET TEXT-BOOK OF SKIN 
DISEASES. In one handsome 12mo. volume of 350 pages, with 
many illustrations. Shortly. Lea's Series of Pocket Text-books, edited 
by Bern B. Gallaudet, M. D. See page 18. 


HABERSHON (S. O.). ON THE DISEASES OF THE ABDOMEN 
Second American from the third English edition. In one octavo vol¬ 
ume of 554 pages, with 11 engravings. Cloth, $3.50. 


HALL (WINFIELD S.). TEXT-BOOK OF PHYSIOLOGY. Octavo 
of 672 pages, with 343 engravings, and 6 full page colored plates. Just 
ready. Cloth, $4.00 ; leather, $5.00, net. 


HAMILTON (ALLAN MCLANE). NERVOUS DISEASES. THEIR 
DESCRIPTION AND TREATMENT. Second and revised edition. 
In one octavo volume of 598 pages, with 72 engravings. Cloth, $4. 


HARDAWAY (W. A.). MANUAL OF SKIN DISEASES. New (2d) 
edition. In one 12mo. volume of 560 pages, with 40 illustrations and 
2 plates. Cloth, $2.25, net. Just ready. 


The best of all the small books to 
recommend to students and practi¬ 
tioners. Probably no one of our 
dermatologists has had a wider every¬ 


day clinical experience. His great 
strength is in diagnosis, descriptions 
of lesions and especially in treat¬ 
ment. —Indiana Medical Journal. 


HARE (HOBART AMORY). PRACTICAL DIAGNOSIS. THE 
USE OF SYMPTOMS IN THE DIAGNOSIS OF DISEASE. New 
(4th) edition. In one octavo volume of 623 pages, with 205 engravings 
and 14 full-page colored plates. Cloth, $5.00, net. Just ready. 


It is unique in many respects, and 
the author has introduced radical 
changes which will be welcomed by 
all. Anyone who reads this book 
will become a more acute observer, 
will pay more attention to the simple utility .—Medical Review. 
yet indicative signs of disease, and 


he will become a better diagnosti¬ 
cian. This is a companion to Prac¬ 
tical Therapeutics, by the same 
author, and it is difficult to conceive 
of any two works of greater practical 








Lea Brothers & Co., Philadelphia and New York. 13 


HARE (HOBART AMORY). A TEXT-BOOK OF PRACTICAL 
THERAPEUTICS, with Special Reference to the Application of Reme¬ 
dial Measures to Disease and their Employment upon a Rational 
Basis. With articles on various subjects by well-known specialists. 
New (7th) and revised edition. In one octavo volume of 776 pages. 
Cloth, $3.75, net; leather, $4.50, net. 


Its classifications are inimitable, 
and the readiness with which any¬ 
thing can be found is the most won¬ 
derful achievement of the art of in¬ 
dexing. This edition takes in all 
the latest discovered remedies.— 
The St. Louis Clinique. 

The great value of the work lies 
in the fact that precise indications 
for administration are given. A 
complete index of diseases and 
remedies makes it an easy reference 
work. It has been arranged so that 


it can be readily used in connection 
with Hare’s Practical Diagnosis. 
For the needs of the student and 
general practitioner it has no equal. 
—Medical Sentinel. 

The best planned therapeutic work 
of the century .—American Prac¬ 
titioner and News. 

It is a book precisely adapted to 
the needs of the busy practitioner, 
who can rely upon finding exactly 
what he needs.— The National Med¬ 
ical Review. 


HARE (HOBART AMORY) ON THE MEDICAL COMPLICA¬ 
TIONS AND SEQUELAE OF TYPHOID FEVER. Octavo, 276 
pages, 21 engravings and two full-page plates. Just ready. Cloth, 
$2.40, net. 

A very valuable production. One read with great profit.— Cleveland. 
of the very best products of Dr. Journal of Medicine. 

Hare and one that every man can 

HARE (HOBART AMORY, EDITOR). A SYSTEM OF PRAC¬ 
TICAL THERAPEUTICS. In a series of contributions by eminent 
practitioners. In four large octavo volumes comprising about 4500 
pages,with about 550 engravings. Vol. IV., just ready. For sale by sub¬ 
scription only. Full prospectus free on application to the Publishers. 
Regular price, Vol. IV., cloth, $6; leather, $7; half Russia, $8. 
Price Vol. IV. to former or new subscribers to complete work, cloth, 
$5 ; leather, $6; half Russia, $7. Complete work, cloth, $20; leather, 
$24; half Russia, $28. 

The great value of Hare’s System of Practical Therapeutics has led to a 
widespread demand for a new volume to represent advances in treatment 
made since the publication of the first three. More than fulfilling this 
request the Editor has secured contributions from practically a new coips 
of equally eminent authors, so that entirely fresh and original mattei is 
ensured. The plan of the work, which proved so successful, has been fol¬ 
lowed in this new volume, which will be found to present the latest devel¬ 
opments and applications of this most practical branch of the medical art. 
The entire System is an unrivalled encyclopaedia on the practical parts of 
medicine, and merits the great success it has won for that reason. 




14 Lea Brothers & Co., Philadelphia and New York. 


HARTSHORNE (HENRY). ESSENTIALS OF THE PRINCIPLES 
AND PRACTICE OF MEDICINE. Fifth edition. In one 12mo. 
volume, 669 pages, with 144 engravings. Cloth, $2.75. 

-A HANDBOOK OF ANATOMY AND PHYSIOLOGY. In one 

12mo. volume of 310 pages, with 220 engravings. Cloth, $1.75. 

-A CONSPECTUS OF THE MEDICAL SCIENCES. Comprising 

Manuals of Anatomy, Physiology, Chemistry, Materia Medica, Prac¬ 
tice of Medicine, Surgery and Obstetrics. Second edition. In one royal 
12mo. vol. of 1028 pages, with 477 illus. Cloth, $4.25; leather, $5. 

HAYDEN (JAMES R.). A MANUAL OF VENEREAL DISEASES. 
New (2d) edition. In one 12mo. volume of 304 pages, with 54 en¬ 
gravings. Cloth, $1.50, net. 


It is practical, concise, definite 
and of sufficient fulness to be satis¬ 
factory. —Chicago Clinical Review. 

This work gives all of the prac¬ 
tically essential information about 
the three venereal diseases, gon¬ 
orrhoea, the chancroid and syphilis. 
In diagnosis and treatment it is par¬ 


ticularly thorough, and may be 
relied upon as a guide in the man¬ 
agement of this class of diseases.— 
Northwestern Lancet. 

It is well written, up to date, and 
will be found very useful.— Inter¬ 
national Medical Magazine. 


HAYEM (GEORGES) AND HARE (H. A ). PHYSICAL AND 
NATURAL THERAPEUTICS. The Remedial Use of Heat, Elec¬ 
tricity, Modifications of Atmospheric Pressure, Climates and Mineral 
Waters. Edited by Prof. H. A. Hare, M. D. In one octavo volume 
of 414 pages,with 113 engravings. Cloth, $3. 


This well-timed up-to-date volume 
is particularly adapted to the re¬ 
quirements of the general practi¬ 
tioner. The section on mineral 
waters is most scientific and prac¬ 
tical. Some 200 pages are given up 
to electricity and evidently embody 
the latest scientific information on 
the subject. Altogether this work 
is the clearest and most practical aid 
to the study of nature’s therapeutics 
that has yet come under our obser 
vation. —The Medical Fortnightly. 

For many diseases the most potent 
remedies lie outside of the materia 
medica, a fact yearly receiving wider 


recognition. Within this large 
range of applicability, physical 
agencies when compared with drugs 
are more direct and simple in their 
results. Medical literature has long 
been rich in treatises upon medical 
agents, but an authoritative work 
upon the other great branch of 
therapeutics has until now been a 
desideratum. The section on climate, 
rewritten by Prof. Hare, will, for 
the first time, place the abundant 
resources of our country at the in¬ 
telligent command of American 
practitioners. — The Kansas City 
Medical Index. 


HERMAN (G. ERNEST). FIRST LINES IN MIDWIFERY. In 

one 12mo. vol. of 198 pages, with 80 engravings. Cloth, $1.25. See 
Student's Series of Manuals, page 27. 

HERMANN (Li.). EXPERIMENTAL PHARMACOLOGY. A Hand¬ 
book of the Methods for Determining the Physiological Actions of 
Drugs. Translated by Robert Meade Smith, M. D. In one 12mo. 
volume ot 199 pages, with 32 engravings. Cloth, $1.50. 







Lea Brothers & Co., Philadelphia and New York. 15 


HERRICK (JAMES B.). A HANDBOOK OF DIAGNOSIS. In 
one handsome 12mo. volume of 429 pages, with 80 engravings and 2 
colored plates. Cloth, $2.50. 


Excellently arranged, practical, 
concise, up-to-date, and eminently 
well fitted for the use of the prac¬ 
titioner as well as of the student.— 
Chicago Med. Recorder. 

This volume accomplishes its ob¬ 
jects more thoroughly and com¬ 
pletely than any similar work yet 
published. Each section devoted to 
diseases of special systems is pre¬ 
ceded with an exposition of the 
methods of physical, chemical and 


microscopical examination to be em¬ 
ployed in each class. The technique 
of blood examination,including color 
analysis, is very clearly stated. 
Uranalysis receives adequate space 
and care. —New York Med. Journal. 

We commend the book not only to 
the undergraduate, but also to the 
physician who desires a ready means 
of refreshing his knowledge of diag¬ 
nosis in the exigencies of professional 
life.— Memphis Medical Monthly. 


HELL. (BERKELEY). SYPHILIS AND LOCAL CONTAGIOUS 
DISORDERS. In one 8vo. volume of 479 pages. Cloth, $3.25. 


HILLtER (THOMAS). A HANDBOOK OF SKIN DISEASES. 
Second edition. In one royal 12mo. volume of 353 pages, with two 
plates. Cloth, $2.25. 

HIRST (BARTON C.) AND PIERSOL (GEORGE A.). HUMAN 
MONSTROSITIES. Magnificent folio, containing 220 pages of text 
and illustrated with 123 engravings and 39 large photographic plates 
from nature. In four parts, price each, $5. Limited edition. For sale 
by subscription only. 

HOBLYN (RICHARD D.). A DICTIONARY OF THE TERMS 
USED IN MEDICINE AND THE COLLATERAL SCIENCES. 
In one 12mo. volume of 520 double-columned pages. Cloth, $1.50 ; 
leather, $2. 

HODGE (HUGH L.). ON DISEASES PECULIAR TO WOMEN, 
INCLUDING DISPLACEMENTS OF THE UTERUS. Second and 
revised edition. In one 8vo. vol. of 519 pp.,with illus. Cloth, $4.50 


HOFFMANN (FREDERICK) AND POWER (FREDERICK B.). 

A MANUAL OF CHEMICAL ANALYSIS, as Applied to the 
Examination of Medicinal Chemicals and their Preparations. Third 
edition, entirely rewritten and much enlarged. In one handsome octavo 
volume of 621 pages, with 179 engravings. Cloth, $4.25. 

HOLMES (TIMOTHY). A TREATISE ON SURGERY. Its Prin¬ 
ciples and Practice. A new American from the fifth English edition. 
Edited by T. Pickering Pick, F.R.C.S. In one handsome octavo vol¬ 
ume of 1008jpages, with 428 engravings. Cloth, $6; leather, $7. 

-A SYSTEM OF SURGERY. With notes and additions by various 

American authors. Edited by John H. Packard, M. D. In three 
very handsome 8vo. volumes containing 3137 double-columned pages, 
with 979 engravings and 13 lithographic plates. Per volume, cloth, $6 ; 
leather, $7 ; half Russia, $7.50. For sale by subscription only. 








16 Lea Brothers & Co., Philadelphia and New York. 


HORNER (WILLIAM E.). SPECIAL ANATOMY AND HIS¬ 
TOLOGY. Eighth edition, revised and modified. In two large 8vo. 
volumes of 1007 pages, containing 320 engravings. Cloth, $6. 

HUDSON (A.). LECTURES ON THE STUDY OF FEVER. In one 
octavo volume of 308 pages. Cloth, $2.50. 


HUTCHISON (ROBERT) AND RAINY (HARRY). CLINICAL 
METHODS. A GUIDE TO THE PRACTICAL STUDY OF 
MEDICINE. In one 12mo. volume of 562 pages, with 137 engrav¬ 
ings and 8 colored plates. Cloth, $3.00. 


A comprehensive, clear and re¬ 
markably up-to-date guide to clinical 
diagnosis. The illustrations are 
plentiful and excellent. As exam¬ 
ples of the more recent additions to 


medical knowledge which receive 
recognition, we mention Widal’s 
test for typhoid and the Neuron 
theory of the nervous system.— 
Montreal Medical Journal. 


HUTCHINSON (JONATHAN). SYPHILIS. In one pocket-size 12mo. 
volume of 542 pages, with 8 chromo-lithographic plates. Cloth, $2.25. 
See Series of Clinical Manuals, p. 25. 


HYDE (JAMES NEVINS). A PRACTICAL TREATISE ON DIS¬ 
EASES OF THE SKIN. New (4th) edition, thoroughly revised. 
In one octavo volume of 815 pages, with 110 engravings and 12 full- 
page plates, 4 of which are colored. Cloth, $5.25; leather, $6.25. 


This edition has been carefully re¬ 
vised, and every real advance has 
been recognized. The work answers 
the needs of the general practitioner, 
the specialist, and the student .—The 
Ohio Med. Jour. 

A treatise of exceptional merit 
characterized by conscientious care 
and scientific accuracy. — Buffalo 
Med. Journal. 

A complete exposition of our 
knowledge of cutaneous medicine as 
it exists to-day. The teaching in¬ 
culcated throughout is sound as well 


as practical .—The American Jour¬ 
nal of the Medical Sciences. 

It is the best one-volume work 
that we know. The student who 
gets this book will find it a useful 
investment, as it will well serve him 
when he goes into practice.— Vir¬ 
ginia Medical Semi-Monthly. 

A full and thoroughly modern 
text-book on dermatology. — The 
Pittsburg Medical Review. 

It is the most practical hand¬ 
book on dermatology with which we 
are acquainted .—The Chicago Med¬ 
ical Recorder. 


JACKSON (GEORGE THOMAS). THE READY-REFERENCE 
HANDBOOK OF DISEASES OF THE SKIN. New (3d) edition. 
In one 12mo. volume of 637 pages, with 75 illustrations and a colored 
plate. Just ready. Cloth, $2.50, net. 


As a student’s manual, it may be 
considered beyond criticism. The 
book is singularly full.— St. Louis 
Medical and Surgical Journal. 


Without doubt forms one of the 
best guides for the beginner in der¬ 
matology that is to be found in the 
English language.— Medicine. 


JAMIESON (W. ALLAN). DISEASES OF THE SKIN. Third 
edition. In one octavo volume of 656 pages, with 1 engraving and 9 
double-page chromo-lithographic plates. Cloth, $6. 







Lea Brothers & Co., Philadelphia and New York. 17 


JEWETT (CHARLES). ESSENTIALS OF OBSTETRICS. In one 
12mo. volume of 356 pages, with 80 engravings and 3 colored plates. 
Cloth, $2.25. Just ready. 

An exceedingly useful manual for ing it in attractive and easily tangi- 
student and practitioner. The au- ble form. The book is well illus- 
thor has succeeded unusually well trated throughout.— Nashville Jour. 
in condensing the text and in arrang- j of Medicine and Surgery. 


- THE PRACTICE OF OBSTETRICS. By American Authors. 

One large octavo volume of 763 pages, with 441 engravings in black 
and colors, and 22 full-page colored plates. Just ready. Cloth, 
$5.00, net; leather, $6.00, net. 

A clear and practical treatise upon the book abounds. The work is 
obstetrics by well-known teachers of sure to be popular with medical 
the subject. A special feature of students, as well as being of extreme 
this work would seem to be the value to the practitioner. — The 
excellent illustrations with which Medical Age. 


JONES (C. HANDF1ELD ). CLINICAL OBSERVATIONS ON 
FUNCTIONAL NERVOUS DISORDERS. Second American edi¬ 
tion. In one octavo volume of 340 pages. Cloth, $3.25. 


JULER (HENRY). A HANDBOOK OF OPHTHALMIC SCIENCE 
AND PRACTICE. Second edition. In one octavo volume of 549 
pages, with 201 engravings, 17 chromo-lithographic plates, test-types of 
Jaeger and Snellen, ana Holmgren’s Color-Blindness Test. Cloth, 
$5.50; leather, $6.50. 


The volume is particularly rich in 
matter of practical value, such as 
directions for diagnosing, use of 
instruments, testing for glasses, for 


color blindness, etc. The sections 
devoted to treatment are singularly 
full and concise.— Medical Age. 


KING (A. F. A.). A MANUAL OF OBSTETRICS. Seventh edition. 
In one 12mo. volume of 573 pages, with 223 illustrations. Cloth, 
$2.50. 


From first to finish it is thoroughly 
practical, ooncise in expression, well 
illustrated, and includes a statement 
of nearly every fact of importance 
discussed in obstetric treatises or 


cyclopedias. The well-arranged 
index renders the book useful to 
the practitioner who is in haste to 
refresh his memory. — Virginia 
Medical Semi-Monthly. 


KIRK (EDWARD C.). OPERATIVE DENTISTRY. Handsome 
octavo of 700 pages, with 751 illustrations. Just ready. See American 
Text-Books of Dentistry , page 2. 


We have only the highest praise 
for this valuable work. It is replete 
in every particular, and surpasses 
anything of the kind heretofore at¬ 


tempted. We can heartily recom¬ 
mend it to the profession.— The 
Ohio Dental Journal. 


KLEIN (E.). ELEMENTS OF HISTOLOGY. New (5th) edition. In 
one 12mo. volume of 506 pages, with 296 engravings. Just ready. 
Cloth, $2.00, net. See Student's Series of Manuals, page 27. 

It is the most complete and con- I This work deservedly occupies a 
cise work of the kind that has yet first place as a text-book on his- 
emanated from the press.— The Med- tology.— Canadian Practitioner, 
ical Age. 











18 Lea Brothers & Co., Philadelphia and New York. 


LANDIS (HENRY G.). THE MANAGEMENT OF LABOR. In one 

handsome 12mo. volume of 329 pages, with 28 illus. Cloth, $1.75. 

L/A ROCHE (R.). YELLOW FEVER. In two 8vo. volumes of 1468 
pages. Cloth, $7. 

LAURENCE (J. Z.) AND MOON (ROBERT C.). A HANDY- 
BOOK OF OPHTHALMIC SURGERY. Second edition. In one 
octavo volume of 227 pages, with 66 engravings. Cloth, $2.75. 

LEA S SERIES OF POCKET TEXT-BOOKS, edited hy Bern 
B. Gallaudet, M. D. Covering the entire field of Medicine in a 
series of 16 very handsome 12mo. volumes of 350-450 pages each, 
profusely illustrated. Compendious, clear, trustworthy and modern. 
The following volumes constitute the series. 

Coates’ Bacteriology and Hygiene. Brockway’s Anatomy. Collins 
and Rockwell’s Physiology. Martin and Rockwell’s Chemistry 
and Physics. Nichols and Vale’s Histology and Pathology. 
Schleif’s Materia Medica, Therapeutics, Medical Latin, etc. Mals- 
bary’s Practice of Medicine. Collins’ Diagnosis. Potts’ Nervous 
and Mental Diseases. Gallaudet’s Surgery. Likes’ Genito¬ 
urinary and Venereal Diseases. Grindon’s Dermatology. Ballen- 
GER and Wippern’s Diseases of the Eye, Ear, Throat and Nose. 
Evans’ Obstetrics. Crockett’s Gynecology. Tuttle’s Diseases or 
Children. 

For separate notices see under various authors’ names. 

LEA (HENRY C.). A HISTORY OF AURICULAR CONFESSION 
AND INDULGENCES IN THE LATIN CHURCH. In three 
octavo volumes of about 500 pages each. Per volume, cloth, $3.00. 

-CHAPTERS FROM THE RELIGIOUS HISTORY OF SPAIN; 

CENSORSHIP OF THE PRESS; MYSTICS AND ILLUMINATI - 
THE ENDEMONIADAS; EL SANTO NlftO DE LA GUARDIA ; 
BRIANDA DE BARDAXI. 12mo., 522 pages. Cloth, $2.50. 

-FORMULARY OF THE PAPAL PENITENTIARY. In one 

octavo volume of 221 pages, with frontispiece. Cloth, $2.50. 

-SUPERSTITION AND FORCE; ESSAYS ON THE WAGER 

OF LAW, THE WAGER OF BATTLE, THE ORDEAL AND 
TORTURE. Fourth edition, thoroughly revised. In one hand¬ 
some royal 12mo. volume of 629 pages. Cloth, $2.75. 

-STUDIES IN CHURCH HISTORY. The Rise of the Temporal 

Power—Benefit of Clergy—Excommunication. New edition. In one 
handsome 12mo. volume of 605 pages. Cloth, $2.50. 

-AN HISTORICAL SKETCH OF SACERDOTAL CELIBACY 

IN THE CHRISTIAN CHURCH. Second edition. In one hand¬ 
some octavo volume of 685 pages. Cloth, $4.50. 

LEHMANN (C. G.). A MANUAL OF CHEMICAL PHYSIOLOGY. 
In one 8vo. volume of 327 pages, with 41 engravings. Cloth, $2.25. 








Lea Brothers & Co., Philadelphia and New York. 19 


LIKES (SYLVAN H.). A POCKET TEXT-BOOK OF GENITO¬ 
URINARY AND VENEREAL DISEASES. In one handsome 
12mo. volume of about 350 pages, with many illustrations. Shortly. 
Lea's Series of Pocket Text-books, edited by Bern B. Gallaudet, 
M. D. See page 18. 

LOOMIS (ALFRED L.) AND THOMPSON (W. GILMAN, 
EDITORS). A SYSTEM OF PRACTICAL MEDICINE. In 
Contributions by Various American Authors. In four very hand¬ 
some octavo volumes of about 900 pages each, fully illustrated in 
in black and colors. Complete work now ready. Per volume, cloth, 
$5; leather, $6; half Morocco, $7. For sale by subscription only. 
Full prospectus free on application to the Publishers. See American 
System of Practical Medicine, page 2. 


LUFF (ARTHUR P.). MANUAL OF CHEMISTRY, for the use of 
Students of Medicine. In one 12mo. volume of 522 pages, with 36 
engravings. Cloth, $2. See Student's Series of Manuals, page 27. 


LYMAN (HENRY M.). THE PRACTICE OF MEDICINE. In one 
very handsome octavo volume of 925 pages, with 170 engravings. 
Cloth, $4.75 ; leather, $5.75. 

Complete, concise, fully abreast of Practical, systematic, complete and 
the times and needed by all students well balanced .—Chicago Med. Re- 
and practitioners.— Univ. Med. Mag. corder. 

An exceedingly valuable text-book. 


LYONS (ROBERT D.). A TREATISE ON FEVER. In one octavo 
volume of 362 pages. Cloth, $2.25. 

MACKENZIE (JOHN NOLAND). ON THE NOSE AND THROAT. 
Handsome octavo, about 600 pages, richly illustrated. Preparing. 


MAISCH (JOHN M.). A MANUAL OF ORGANIC MATERIA 
MEDICA. New (7tli) edition, thoroughly revised by H. C. C. Maisch, 
Ph. G., Ph. D. In one very handsome 12mo. volume of 512 pages, with 
285 engravings. Just ready. Cloth, $2.50, net. 


Used as text-book in every college 
of pharmacy in the United States 
and recommended in medical col¬ 
leges .—American Therapist. 

Noted on both sides of the Atlantic 
and esteemed as much in Germany as 


in America. The work has no equal. 
—Dominion Med. Monthly. 

The best handbook upon phar¬ 
macognosy of any published in this 
country .—Boston Med. & Sur. Jonr. 











20 Lea Brothers & Co., Philadelphia and New York. 


MALSBARY (GEORGE E.). A POCKET TEXT-BOOK OF 
THEORY AND PRACTICE OF MEDICINE. In one handsome 
12mo. volume of 405 pages, with 45 illustrations. Just ready.. Cloth, 
$1.75, net; flexible redi leather, $2.25, net. Lea’s Series of Pocket 
Text-books, edited by Bern B. Gallaudet, M. D. See page 18. 


MANUALS. See Student’s Quiz Series, page 27, Student’s Series of 
Manuals, page 27, and Series of Clinical Manuals, page 25. 

MARSH (HOWARD). DISEASES OF THE JOINTS. In one 12mo. 
volume of 468 pages, with 64 engravings and a colored plate. Cloth, $2. 
See Series of Clinical Manuals, page 25. 

MARTIN (EDWARD). A MANUAL OF SURGICAL DIAGNOSIS. 
In one 12mo. volume of about 400 pp., fully illustrated. Preparing. 

MARTIN (WALTON) AND ROCKWELL (WM. H). A POCKET 
TEXT-BOOK OF CHEMISTRY AND PHYSICS. In one hand¬ 
some 12mo. volume of about 350 pages, with many illustrations. 
Shortly. Lea s Series of Pocket Text-books, edited by Bern B. 
Gallaudet, M. D. See page 18. 


MAY (C. H.). MANUAL OF THE DISEASES OF WOMEN. For 
the use of Students and Practitioners. Second edition, revised by L. 
S. Rau, M. D. In one 12mo. volume of 360 pages, with 31 engrav¬ 
ings. Cloth, $1.75. 


MEDICAL NEWS POCKET FORMULARY, see page 32. 


MITCHELL (S. WEIR). CLINICAL LESSONS ON NERVOUS 
DISEASES. In one 12mo. volume of 299 pages, with 19 engravings 
and 2 colored plates. Cloth, $2.50. Of the hundred numbered copies 
with the Author’s signed title page a few remain; these are offered 
in green cloth, gilt top, at $3.50, net. 


The booktreats of hysteria, recur¬ 
rent melancholia, disorders of sleep, 
choreic movements, false sensations 
of cold, ataxia, hemiplegic pain, 
treatment of sciatica, ervthromelal- 
gia, reflex ocularneurosis, hysteric 


contractions, rotary movements in 
the feeble minded, etc. Few can 
speak with more authority than the 
author.— The Journal of the Ameri¬ 
can Medical Association. 


MITCHELL (JOHN K.). REMOTE CONSEQUENCES OF IN¬ 
JURIES OF NERVES AND THEIR TREATMENT. In one 
handsome 12mo. volume of 239 pages,with 12 illustrations. Cloth, $1.75. 


Injuries of the nerves are of fre¬ 
quent occurrence in private practice, 
and often the cause of intractable 
and painful conditions, conse¬ 
quently this volume is of especial 
interest. Doctor Mitchell has had 


access to hospital records for the last 
thirty years, as well as to the 
government documents, and has 
skilfully utilized his opportunities. 
— The Med. Age. 


MORRIS (MALCOLM). DISEASES OF THE SKIN. New (2d) 
edition. In one 12mo. volume of 601 pages, with 10 chromo-litho- 
graphic plates and 26 engravings. Cloth, $3.25, net. Just ready. 

MULLER (J.). PRINCIPLES OF PHYSICS AND METEOROL¬ 
OGY. In one large 8vo. vol. of 623 pages, with 638 cuts. Cloth, $4.60. 






Lea Brothers & Co., Philadelphia and New York. 21 


MTJSSER (JOHN H.). A PRACTICAL TREATI8E ON MEDICAL 
DIAGNOSIS, for Students and Physicians. New (3d) edition, thor¬ 
oughly revised. In one octavo volume of 1082 pages, with 253 en¬ 
gravings and 48 full-page colored plates. Just ready. Cloth, $6.00, 
net; leather, $7.00, net. 

Notices of previous edition are appended. 


We have no work of equal value 
in English. — University Medical 
Magazine. 

His descriptions of the diagnostic 
manifestations of diseases are accu¬ 
rate. This work will meet all the 
requirements of student and physi¬ 
cian.— The Medical News. 

From its pages may be made the 
diagnosis of every malady that 
afflicts the human body, including 
those which in general are dealt 
with only by the specialist.— North¬ 
western Lancet. 


It so thoroughly meets the precise 
demands incident to modern research 
that it has been adopted as a leading 
text-book by the medical colleges 
of this country.— North American 
Practitioner. 

Occupies the foremost place as a 
thorough, systematic treatise.— Ohio 
Medical Journal. 

The best of its kind, invaluable to 
the student, general practitioner and 
teacher.— Montrea l Medica l Journa l. 


NATIONAL DISPENSATORY. See Stille, Maisch & Campari, p. 27. 

NATIONAL FORMULARY. See Stille, Maisch & Caspar Vs National 
Dispensatory, page 27. 

NATIONAL MEDICAL DICTIONARY. See Billings, page 4. 


NETTLESHIP (E.). DISEASES OF THE EYE. New (5th) American 
from sixth English edition, thoroughly revised. In one 12mo. volume 
of 521 pages, with 161 engravings, and 2 colored plates, test-types, 
formulae and color-blindness test. Cloth, $2.25. Just ready. 

By far the best student’s text-book English language. — Journal of 
on the subject of ophthalmology and Medicine and Science. 
is conveniently and concisely ar-1 The present edition is the result 
ranged.— The Clinical Review. of revision both in England and 

It has been conceded by ophthal- America, and therefore contains the 
mologists generally that this work latest and best ophthalmological 
for compactness, practicality and ideas of both continents.— ThePliy- 
clearness has no superior in the sician and Surgeon. 


NICHOLS (JOHN B.) AND YALE (F. P.). A POCKET TEXT¬ 
BOOK OF HISTOLOGY AND PATHOLOGY. In one handsome 
12mo. volume of 452 pages, Avith 213 illustrations. Just ready. Cloth, 
$1.75, net: flexible red leather, $2.25, net. 

Lea's Series of Pocket Text-books, edited by Bern B. Gallaudet, 
M. D. See page 18. 


NORRIS fWM. F.) AND OLIVER (CHAS. A.). TEXT-BOOK OF 
OPHTHALMOLOGY. In one octavo volume of 641 pages, with 357 
engravings and 5 colored plates. Cloth, $5 ; leather, $6. 


A safe and admirable guide, Avell 
qualified to furnish a working 
knowledge of ophthalmology. — 
Johns Hopkins Hospital Bulletin. 

It is practical in its teachings. 
We unreservedly endorse it as the 


best, the safest and the most compre¬ 
hensive volume upon the subject that 
has ever been offered to the Amer¬ 
ican medical public.— Annals of 
Ophthalmology and Otology. 





22 TiicA Brothers &*Co., Philadelphia and New York. 


OWEN (EDMUND). SURGICAL DISEASES OF CHILDREN. 

In one 12mo. volume of 525 pages, with 85 engravings and 4 colored 
plates. Cloth, $2. See Series of Clinical Manuals, page 25. 


PARK (ROSWELL). A TREATISE ON SURGERY BY AMERI¬ 
CAN AUTHORS. New and condensed edition. Just ready. 
In one royal octavo volume of 1261 pages, with 625 engravings 
and 37 full-page plates. Cloth, $6.00, net; leather, $7.00, net. 
jS^This work is also published in a larger edition, comprising two 
volumes. Volume I., General Surgery, 799 pages, with 356 engravings 
and 21 full-page plates, in colors and monochrome. Volume II., 
Special Surgery, 800 pages, with 430 engravings and 17 full-page 
plates, in colors and monochrome. Per volume, cloth, $4.50; leather, 
$5.50, net. 


The work is fresh, clear and practi¬ 
cal, covering the ground thoroughly 
yet briefly, and well arranged for 
rapid reference, so that it will be of 
special value to the student and busy 
ractitioner. The pathology is 
road, clear and scientific, while the 
suggestions upon treatment are 
clear-cut, thoroughly modern and 
admirably resourceful.— Johns Hop¬ 
kins Hospital Bulletin. 

The latest and best work written 
upon the science and art of surgery. 
Columbus Medical Journal. 

The illustrations are almost en¬ 
tirely new and executed in such a 


way that they add great force to the 
text.— The Chicago Medical Re¬ 
corder. 

The various writers have em¬ 
bodied the teachings accepted at 
the present hour.— The North Amer¬ 
ican Practitioner. 

Both for the student and practi¬ 
tioner it is most valuable. It is 
thoroughly practical and yet thor¬ 
oughly scientific.— Medical News. 

A truly modern surgery, not only 
in pathology, but also in sound 
surgical therapeutics. — New Or¬ 
leans Med. and Surgical Journal. 


PARK (WILLIAM H.). BACTERIOLOGY IN MEDICINE AND 
SURGERY. 12mo., 688 pages, with 87 illustrations in black and 
colors, and 2 plates. Just ready. Cloth, $3.00 net. 


PARRY (JOHN S.). EXTRA-UTERINE PREGNANCY, ITS 
CLINICAL HISTORY, DIAGNOSIS, PROGNOSIS AND TREAT¬ 
MENT. In one octavo volume of 272 pages. Cloth, $2.50. 


PARVIN (THEOPHILUS). THE SCIENCE AND ART OF OB¬ 
STETRICS. Third edition. In one handsome octavo volume of 


677 pages, with 267 engravings 
leather, $5.25. 

In the foremost rank among the 
most practical and scientific medical 
works of the day.— Medical News. 

The book is complete in every de¬ 
partment, and contains all the neces¬ 
sary detail required by the modern 


and 2 colored plates. Cloth, $4.25; 


practising obstetrician. — Interna¬ 
tional Medical Magazine. 

Parvin’s work is practical, con¬ 
cise and comprehensive. We com¬ 
mend it as first of its class in the 
English language.— Medical Fort¬ 
nightly. 







Lea Brothers & Co., Philadelphia and New York. 23 


PEPPER’S SYSTEM OF MEDICINE. See page 3. 

PEPPER (A. J.). FORENSIC MEDICINE. In press. See Student’s 
Series of Manuals, page 27. 

-SURGICAL PATHOLOGY. In one 12mo. volume of 511 pages, 

with 81 engravings. Cloth, $2. See Student’s Series of Manuals, p. 27. 

PICK (T. PICKERING). FRACTURES AND DISLOCATIONS. 
In one 12mo. volume of 530 pages, with 93 engravings. Cloth, $2. 
See Series of Clinical Manuals, page 25. 


PLAYFAIR (W. S.). A TREATISE ON THE SCIENCE AND 
PRACTICE OF MIDWIFERY. Seventh American from the ninth 
English edition. In one octavo volume of 700 pages, with 207 
engravings and 7 plates. Cloth, $3.75 net; leather, $4.75, net. Just 
ready. 


In the numerous editions which 
have appeared it has been kept con¬ 
stantly in the foremost rank. It is 
a work which can be conscientiously 
recommended to the profession.— 
The Albany Medical Annals. 

This work must occupy a fore¬ 
most place in obstetric medicine as 
a safe guide to both student and 


obstetrician. It holds a place among 
the ablest English-speaking authori¬ 
ties on the obstetric art.— Buffalo 
Medical and Surgical Journal. 

An epitome of the science and 
practice of midwifery, which em¬ 
bodies all recent advances. — The 
Medical Fortnightly. 


— THE SYSTEMATIC TREATMENT OF NERVE PROSTRA¬ 
TION AND HYSTERIA. In one 12mo. volume of 97 pages. 
Cloth, $1. 


POCKET FORMULARY, see page 32. 


POCKET TEXT-BOOKS, see page 18. 


POLITZER (ADAM). A TEXT-BOOK OF THE DISEASES OF THE 
EAR AND ADJACENT ORGANS. Second American from the 
third German edition. Translated by Oscar Dodd, M. D., and 
edited by Sir William Dalby, F. R. C. S. In one octavo volume of 
748 pages, with 330 original engravings. Cloth, $5.50. 

The anatomy and physiology of f ment are clear and reliable. We 
each part of the organ of hearing 
carefully considered, and then 


are 


follows an enumeration of the dis¬ 
eases to which that special part of 
the auditory apparatus is especially 
liable. The indications for treat- 


are 

can confidently recommend it, for it 
contains all that is known upon the 
subject.— London Lancet. 

A safe and elaborate guide into 
every part of otology.— American 
Journal of the Medical Sciences. 


POTTS (CHARLES S.). A POCKET TEXT-BOOK OF NERVOUS 
AND MENTAL DISEASES. In one handsome 12mo. volume of 
about 450 pages. Shortly. Lea’s Series of Pocket Text-books, edited by 
Bern B. Gallaudet, M. D. See page 18. 

PROGRESSIVE MEDICINE, see page 32. 

PURDY (CHARLES W.). BRIGHT’S DISEASE AND ALLIED 
AFFECTIONS OF THE KIDNEY. In one octavo volume of 288 
pages, with 18 engravings. Cloth, $2. 







24 Lea Brothers & Co., Philadelphia and New York. 


PYE-SMITH (PHILIP H.). DISEASES OF THE SKIN. In one 
12mo. vol. of 407 pp., with 28 illus., 18 of which are colored. Cloth, $2. 

QUIZ SERIES. See Student's Quiz Series , page 27. 

RALFE (CHARLES H.). CLINICAL CHEMISTRY. In one 
12mo. volume of 314 pages, with 16 engravings. Cloth, $1.50. See 
Student's Series of Manuals , page 27. 


RAMSBOTHAM (FRANCIS H.). THE PRINCIPLES AND PRAC¬ 
TICE OF OBSTETRIC MEDICINE AND SURGERY. In one 
imperial octavo volume of 640 pages, with 64 plates and numerous 
engravings in the text. Strongly bound in leather, $7. 

REICHERT (EDWARD T.). A TEXT-BOOK ON PHYSIOLOGY. 
In one handsome octavo volume of about 800 pages, richly illustrated. 
Preparing. 


REMSEN (IRA). THE PRINCIPLES OF THEORETICAL CHEM¬ 
ISTRY. New (5th) edition, thoroughly revised. In one 12mo. vol¬ 
ume of 326 pages. Cloth, $2. 


A clear and concise explanation 
of a difficult subject. We cordially 
recommend it.— The London Lancet. 

The book is equally adapted to the 
student of chemistry or the practi¬ 
tioner who desires to broaden his 
theoretical knowledge of chemistry. 
—New Orleans Med. and Surg. Jour. 

The appearance of a fifth edition 
of this treatise is in itself a guarantee 


that the work has met with general 
favor. This is further established 
by the fact that it has been trans¬ 
lated into German and Italian. The 
treatise is especially adapted to the 
laboratory student. It ranks unusu¬ 
ally high among the works of this 
class. This edition has been brought 
fully up to the times.— American 
Medico-Surgical Bulletin. 


RICHARDSON (BENJAMIN WARD). PREVENTIVE MEDI¬ 
CINE. In one octavo volume of 729 pages. Cloth, $4 ; leather, $5. 

ROBERTS (JOHN B.). THE PRINCIPLES AND PRACTICE OF 
MODERN SURGERY. New (2d) edition. In one octavo volume of 
838 pages with 473 engravings and 8 plates. Just ready. Cloth, $4.25, 
net; leather, $5.25, net. 


- THE COMPEND OF ANATOMY. For use in the Dissecting 

Room and in preparing for Examinations. In one 16mo. volume of 
196 pages. Limp cloth, 75 cents. 

ROBERTS (SIR WILLIAM). A PRACTICAL TREATISE ON 
URINARY AND RENAL DISEASES, INCLUDING URINARY 
DEPOSITS. Fourth American from the fourth London edition. In 
one very handsome 8vo. vol. of 609 pp., with 81 illus. Cloth, $3.50. 

ROBERTSON (J. MCGREGOR). PHYSIOLOGICAL PHYSICS. 
In one 12mo. volume of 537 pages, with 219 engravings. Cloth, $2. 
See Student's Series of Manuals , page 27. 

ROSS (JAMES). A HANDBOOK OF THE DISEASES OF THE 
NERVOUS SYSTEM. In one handsome octavo volume of 726 pages, 
with 184 engravings. Cloth, $4.50 ; leather, $5.50. 

SAVAGE (GEORGE H.). INSANITY AND ALLIED NEUROSES, 
PRACTICAL AND CLINICAL. In one 12mo. volume of 551 pages, 
with 18 typical engravings. Cloth, $2. See Series of Clinical Man¬ 
uals, page 25. 





Lea Brothers & Co., Philadelphia and New York. 25 


SCHAFER (EDWARD A.). THE ESSENTIALS OF HISTOL¬ 
OGY, DESCRIPTIVE AND PRACTICAL. For the use of Students. 
New (oth) edition. In one handsome octavo volume of 359 pages, 
with 392 illustrations. Cloth, $3.00, net. Just ready. 


Nowhere else will the same very 
moderate outlay secure as thoroughly 
useful and interesting an atlas of 
structural anatomy. — The American 
Journal of the Medical Sciences. 


The most satisfactory elementary 
text-book of histology in the Eng¬ 
lish language.— The Boston Med. and 
Sur. Jour. 


-A COURSE OF PRACTICAL HISTOLOGY. New (2d) edition. 

In one 12mo. volume of 307 pages, with 59 engravings. Cloth, $2.25. 

SCHLEIF (WILLIAM). MATERIA MEDICA, THERAPEUTICS, 
PRESCRIPTION WRITING, MEDICAL LATIN, ETC. 12mo.| 
352 pages. Cloth, $1.50, net; flexible red leather, $2.00, net. Just 
ready. Lea’s Series of Pocket Text-books. Edited by Bern B. 
Gallaudet, M. D. See page 18. 

SCHMITZ AND ZUMPT’S CLASSICAL SERIES. Advanced 
Latin Exercises. Cloth, 60 cts. Schmidt’s Elementary Latin Exer¬ 
cises. Cloth, 50 cents. Sallust. Cloth, 60 cents. Nepos. Cloth, 60 
cents. Virgil. Cloth, 85 cents. Curtius. Cloth, 80 cents. 

SCHOFIELD (ALFRED T.). ELEMENTARY PHYSIOLOGY 
FOR STUDENTS. In one 12mo. volume of 380 pages, with 227 
engravings and 2 colored plates. Cloth, $2. 

SCHREIBER (JOSEPH). A MANUAL OF TREATMENT BY 
MASSAGE AND METHODICAL MUSCLE EXERCISE. Octavo 
volume of 274 pages, with 117 engravings. 

SENN (NICHOLAS). SURGICAL BACTERIOLOGY. Second edi¬ 
tion. In one octavo volume of 268 pages, with 13 plates, 10 of which 
are colored, and 9 engravings. Cloth, $2. 

SERIES OF CLINICAL MANUALS. A Series of Authoritative 
Monographs on Important Clinical Subjects, in 12mo. volumes of about 
550 pages, well illustrated. The following volumes are now ready: 
Yeo on Food in Health and Disease, new (2d) edition, $2.50; Carter 
and Frost’s Ophthalmic Surgery, $2.25; Hutchinson on Syphilis, 
$2.25; Marsh on Diseases of the Joints, $2; Owen on SurgicalDis- 
eases of Children, $2; Pick on Fractures and Dislocations, $2; Savage 
on Insanity and Allied Neuroses, $2. 

For separate notices, see under various authors’ names. 


SERIES OF STUDENT’S MANUALS. See page 27. 

SIMON (CHARLES E.). CLINICAL DIAGNOSIS, BY MICRO¬ 
SCOPICAL AND CHEMICAL METHODS. New (2d) edition. In 
one very handsome octavo volume of 530 pages, with 135 engravings 
and 14 full-page colored plates. Cloth, $3.50. Just ready. 

This book thoroughly deserves its In all respects entirely up to date, 
success. It is a very complete, authen- — Medical Record. 
tic and useful manual of the micro- The chapter on examination oi 
scopical and chemical methods the urine is the most complete and 


which are employed in diagnosis. 
Very excellent colored plates illus¬ 
trate this work.— New York Medical 

Journal. 


advanced that we 
English language.- 
titioner. 


know of in the 

-Canadian Prac- 









26 Lea Brothers & Co., Philadelphia and New York. 


SIMON (W.). MANUAL OF CHEMISTRY. A Guide to Lectures 
and Laboratory Work for Beginners in Chemistry. A Text-book 
specially adapted for Students of Pharmacy and Medicine. New (6th) 
edition. In one 8vo. volume of 536 pages, with 46 engravings and 8 
plates showing colors of 64 tests. Cloth, $3.00, net. Just ready. 


It is difficult to see how a better 
book could be constructed. No man 
who devotes himself to the practice 
of medicine need know more about 
chemistry than is contained between 


the covers of this book.— The North¬ 
western Lancet. 

Its statements are all clear and its 
teachings are practical.— Virginia 
Med. Monthly. 


SLADE (D. D.). DIPHTHERIA; ITS NATURE AND TREAT¬ 
MENT. Second edition. In one royal 12mo. vol., 158 pp. Cloth, $1.25. 


SMITH (EDWARD). CONSUMPTION; ITS EARLY AND REME¬ 
DIABLE STAGES. In one 8vo. volume of 253 pp. Cloth, $2.25. 


SMITH (J. LEWIS). A TREATISE ON THE DISEASES OF IN¬ 
FANCY AND CHILDHOOD. Eighth edition, thoroughly revised 
and rewritten and much enlarged. In one large 8vo. volume of 983 


pages, with 273 engravings ai 
leather, $5.50. 

A safe guide for students and phy¬ 
sicians. — The Am. Jour, of Obstetrics. 

For years the leading text-book on 
children’s diseases in America.— 
Chicago Medical Recorder. 


1 4 full-page plates. Cloth, $4.50; 

The most complete and satisfac¬ 
tory text-book with which we are 
acquainted. —American Gynecologi¬ 
cal and Obstetrical Journal. 


SMITH (STEPHEN). OPERATIVE SURGERY. Second and thor¬ 
oughly revised edition. In one octavo volume of 892 pages, with 
1005 engravings. Cloth, $4 ; leather, $5. 

One of the most satisfactory works dium for the modern surgeon.— Bos¬ 
on modern operative surgery yet ton Medical and Surgical Journal. 
published. The book is a compen- 


SOLLY (S. EDWIN). A HANDBOOK OF MEDICAL CLIMA¬ 
TOLOGY. In one handsome octavo volume of 462 pages, with en¬ 
gravings and 11 full-page plates, 5 of which are in colors. Cloth, $4.00. 
Just ready. 


A clear and lucid summary of 
what is known of climate in relation 
to its influence upon human beings. 
— The Therapeutic Gazette. 

The book is admirably planned, 
clearly written ,and the author speaks 
from an experience of thirty years as 


an accurate observer and practical 
therapeutist. —Maryland Med. Jour. 

Every practitioner of medicine 
should possess himself of a copy and 
study it, and we are sure he will 
never regret it. — St. Louis Medical 
and Surgical Journal. 


STILLE (ALFRED). CHOLERA; ITS ORIGIN, HISTORY, CAUS¬ 
ATION, SYMPTOMS, LESIONS, PREVENTION AND TREAT¬ 
MENT. In one 12mo. volume of 163 pages, with a chart showing 
routes of previous epidemics. Cloth, $1.25. 


— THERAPEUTICS AND MATERIA MEDICA. Fourth and 
revised edition. In two octavo volumes, containing 1936 pages. 
Cloth, $10; leather, $12. 








Lea Brothers & Co., Philadelphia and New York. 27 


STILLE (ALFRED), MAISCH (JOHN M.) AND CASPARI 

(CHAS. JR.). THE NATIONAL DISPENSATORY: Containing 
the Natural History, Chemistry, Pharmacy, Actions and Uses of 
Medicines, including those recognized in the latest Pharmacopoeias of 
the United States, Great Britain and Germany, with numerous refer¬ 
ences to the French Codex. Fifth edition, revised and enlarged, 
including the new U. S. Pharmacopoeia, Seventh Decennial Revision. 
With Supplement containing the new edition of the National Formu¬ 
lary. In one magnificent imperial octavo volume of about 2025 pages, 
with 320 engravings. Cloth, $7.25; leather, $8. With ready reference 
Thumb-letter Index. Cloth, $7.75 ; leather, $8.50. 


STIMSON (LEWIS A.). A MANUAL OF OPERATIVE SURGERY. 


New (3d) edition. In one royal 
engravings. Cloth, $3.75. 

A useful and practical guide for 
all students and practitioners.— Am. 
Journal of the Medical Sciences. 


12mo. volume of 614 pages, with 306 

The book is worth the price for the 
illustrations alone.— Ohio Medical 
Journal. 


STIMSON (LEWIS A.). A TREATISE ON FRACTURES AND 

DISLOCATIONS. In one handsome octavo volume of 831 pages, 
with 326 engravings and 20 plates. Cloth, $5.00, net; leather, 
$6.00, net. 


Preeminently the authoritative 
text-book upon the subject. The 
vast experience of the author gives 
to his conclusions an unimpeachable 
value. The work is profusely il¬ 
lustrated. It will be found indis¬ 
pensable to the student and the prac¬ 
titioner alike .—The Medical Age. 


Taken as a whole, the work is the 
best one in English to-day.— St. 
Louis Medical and Surgical Journal. 

Pointed, practical, comprehensive, 
exhaustive, authoritative, well writ¬ 
ten and well arranged .—Denver 
Medical Times. 


STUDENT’S QUIZ SERIES. Thirteen volumes, convenient, author¬ 
itative, well illustrated, handsomely bound in cloth. 1. Anatomy 
(double number); 2. Physiology; 3. Chemistry and Physics; 4. Histol¬ 
ogy, Pathology, and Bacteriology; 5. Materia Medica and Thera¬ 
peutics ; 6. Practice of Medicine; 7. Surgery (double number); 8. Genito¬ 
urinary and Venereal Diseases; 9. Diseases of the Skin; 10. Diseases 
of the Eye, Ear, Throat and Nose; 11. Obstetrics; 12. Gynecology; 
13. Diseases of Children. Price, $1 each, except Nos. 1 and 7, 
Anatomy and Surgery, which being double numbers are priced at 
$1.75 each. Full specimen circular on application to publishers. 

STUDENT’S SERIES OF MANUALS. 12mos. of from 300-540 
pages, profusely illustrated, and bound in red limp cloth. Herman’s 
First Lines in Midwifery, $1.25; Luff’s Manual of Chemistry, $2; 
Bruce’s Materia Medica and Therapeutics (sixth edition), $1.50. net. 
Bell’s Comparative Anatomy and Physiology, $2; Robert¬ 
son’s Physiological Physics, $2; Gould’s Surgical Diagnosis, $2; 
Klein’s Elements of Histology (5tb edition), $2.00, net; Peppers 
Surgical Pathologv, $2; Treves’ Surgical Applied Anatomy, $2 ; 
IUlfe’s Clinical Chemistry, $1.50; and Clarke and Lockwood s 
Dissector’s Manual, $1.50. The following is in press: Peppers 
Forensic Medicine. 

For separate notices, see under various author s name*. 





28 Lea Brothers A Co., Philadelphia and New York. 


STURGES (OCTAVIUS). AN INTRODUCTION TO THE STUDY 
OF CLINICAL MEDICINE. In one 12mo. volume. Cloth, $1.25. 

SUTTON (JOHN BLAND). SURGICAL DISEASES OF THE 
OVARIES AND FALLOPIAN TUBES. Including Abdominal 
Pregnancy. In one 12mo. volume of 513 pages, with 119 engravings 
and 5 colored plates. Cloth, $3. 

TAIT (LAWSON). DISEASES OF WOMEN AND ABDOMINAL 
SURGERY. Vol. I. contains 546 pages and 3 plates. Cloth, $3. 


TANNER (THOMAS HAWRES) ON THE SIGNS AND DIS¬ 
EASES OF PREGNANCY. From the second English edition. In 
one octavo volume of 490 pages, with 4 colored plates and 16 engrav¬ 
ings. Cloth, $4.25 


TAYLOR (ALFRED S.). MEDICAL JURISPRUDENCE. New 

American from the twelfth English edition, specially revised by CLARK 
Bell, Esq., of the N. Y. Bar. In one 8vo. vol. of 831 pages, with 54 
engrs. and 8 full-page plates. Cloth, $4.50; leather, $5.50 Just ready. 


To the student, as to the physician, 
we would say, get Taylor first, and 
then add as means and inclination 
enable you.— American Practitioner 
and Neivs. 

It is the authority accepted as 
final by the courts of all English- 
speaking countries. This is the im¬ 
portant consideration for medical 
men, since in the event of their 
being summoned as experts or wit¬ 


nesses, it strongly behooves them to 
be prepared according to the princi¬ 
ples and practice everywhere ac¬ 
cepted. The work will be found to 
be thorough, authoritative and 
modern.— Albany Law Journal. 

Probably the best work on the 
subject written in the English lan¬ 
guage. The work has been thor¬ 
oughly revised and is up to date.— 
Pacific Medical Journal. 


— ON POISONS IN RELATION TO MEDICINE AND MEDI¬ 
CAL JURISPRUDENCE. Third American from the third London 
edition. In one octavo volume of 788 pages, with 104 illustrations. 
Cloth, $5.50; leather, $6.50. 


TAYLOR (ROBERT W.). THE PATHOLOGY AND TREAT¬ 
MENT OF VENEREAL DISEASES. In one very handsome octavo 
volume of 1002 pages, with 230 engravings and 8 colored plates. 
Cloth, $5.00, net; leather, $6.00, net. 


By long odds the best work on 
venereal diseases.— Louisville Medi¬ 
cal Monthly. 

In the observation and treatment 
of venereal diseases his experience 
has been greater probably than that 
of any other practitioner of this con¬ 
tinent.— New York Medical Journal. 

The clearest, most unbiased and 
ably presented treatise as yet pub¬ 
lished on this vast subject.— The 
Medical News. 

Decidedly the most important and 
authoritative treatise on venereal 


diseases that has in recent years ap¬ 
peared in English.— American Jour¬ 
nal of the Medical Sciences. 

It is a veritable storehouse of our 
knowledge of the venereal diseases. 
It is commended as a conservative, 
practical, full exposition of the 
greatest value.— Chicago Clinical 
Review. 

The best work on venereal dis¬ 
eases in the English language. It 
is certainly above everything of the 
kind.— The St. Louis Medical and 
Surgical Journal. 






Lea Brothers & Co., Philadelphia and New York. 29 


TAYLOR (ROBERT W.). A PRACTICAL TREATISE ON SEX¬ 
UAL DISORDERS IN THE MALE AND FEMALE. In one 
8vo. vol. of 448 pp., with 73 engravings and 8 colored plates. 

The author has presented to the followed, will be of unlimited value 
profession the ablest and most scien- to both physician and patient.— 
tific work as yet published on sexual Medical News. 
disorders, and one which, if carefully 


—A CLINICAL ATLAS OF VENEREAL AND SKIN DISEASES. 
Including Diagnosis, Prognosis and Treatment. In eight large folio 
parts, measuring 14 x 18 inches, and comprising 213 beautiful figures 
on 58 full-page chromo-lithographic plates, 85 fine engravings and 425 
pages of text. Complete work now ready. Price per part, sewed in 
heavy embossed paper, $2.50. Bound in one volume, half Russia, 
$27 ; half Turkey Morocco, $28. For sale by subscription only. Address 
the publishers. Specimen plates by mail on receipt of ten cents. 


TAYLOR (SEYMOUR). INDEX OF MEDICINE. A Manual for 
the use of Senior Students and others. In one large 12mo. volume of 
802 pages. Cloth, $3.75. 


THOMAS (T. GAILLARD) AND MUNDE (PAUL F.). A PRAC¬ 
TICAL TREATISE ON THE DISEASES OF WOMEN. Sixth 
edition, thoroughly revised by Paul F. Munde, M. D. In one 
large and handsome octavo volume of 824 pages, with 347 engravings. 
Cloth, $5; leather, $6. 


The best practical treatise on the 
subject in the English language. 
It will be of especial value to the 
general practitioner as well as to the 
specialist. The illustrations are very 
satisfactory. Many of them are new 
and are particularly clear and attrac¬ 
tive.— Boston Med. and Sur. Jour. 


This work, which has already gone 
through five large editions, and has 
been translated into French, Ger¬ 
man, Spanish and Italian, is the 
most practical and at the same time 
the most complete treatise upon the 
subject.— The Archives of Gynecol¬ 
ogy, Obstetrics and Pediatrics. 


THOMPSON (SIR HENRY). CLINICAL LECTURES ON DIS¬ 
EASES OF THE URINARY ORGANS. Second and revised edi¬ 
tion. In one octavo vol. of 203 pp., with 25 engravings. Cloth, $2.25* 

-THE PATHOLOGY AND TREATMENT OF STRICTURE 

OF THE URETHRA AND URINARY FISTULAS. From the 
third English edition. In one octavo volume of 359 pages, with 47 
engravings and 3 lithographic plates. Cloth, $3.50. 

THOMSON (JOHN). DISEASES OF CHILDREN. In one crown 
octavo volume of350 pages, with 52 illus. Cloth, $1.75, net. Just ready. 

TODD (ROBERT BENTLEY). CLINICAL LECTURES ON CER¬ 
TAIN ACUTE DISEASES. In one 8vo. vol. of 320 pp., cloth, $2.50. 

TREVES (FREDERICK). OPERATIVE SURGERY. In two 
8vo. vols. containing 1550 pp., with 422 illus. Cloth, $9 ; leath., $11. 

-A SYSTEM OF SURGERY. In Contributions by Twenty-five 

English Surgeons. In two large octavo volumes. Vol. I., 1178 pages, 
with 463 engravings and 2 colored plates. Vol. II., 1120 pages, with 
487 engravings and 2 colored plates. Complete work, cloth. $16.00. 









30 Lea Brothers & Co., Philadelphia and New York. 


TREVES (FREDERICK). SURGICAL APPLIED ANATOMY. In 
one 12mo. volume of 540 pages, with 61 engravings. Cloth, $2. See 
Student's Series of Manuals, page 27. 

TUTTLE (GEORGE M.). A POCKET TEXT-BOOK OF DISEASES 
OF CHILDREN. In one handsome 12mo. volume of 374 pages, 
with 5 plates. Just ready. Cloth, $1.50, net; flexible red leather, 
$2.00, net. Lea's Series of Pocket Text-books, edited by Bern B. 
Gallaudet, M. D. See p. 18 . 


VAUGHAN (VICTOR C.) AND NOVY (FREDERICK G.). 

PTOMAINS, LEUCOMAINS, TOXINS AND ANTITOXINS, 
or the Chemical Factors in the Causation of Disease. New (3d) edition. 
In one 12mo. volume of 603 pages. Cloth, $3. 


The work has been brought down 
to date, and will be found entirely 
satisfactory.— Journal of the Ameri¬ 
can Medical Association. 

The most exhaustive and most re¬ 
cent presentation of the subject.— 
American Jour, of the Med. Sciences. 


The present edition has been not 
only thoroughly revised throughout 
but also greatly enlarged, ample 
consideration being given to the new 
subjects of toxins and antitoxins.— 
Tri-State Medical Journal. 


VISITING LIST. THE MEDICAL NEWS VISITING LIST for 1900. 
Four styles: Weekly (dated for 30 patients); Monthly (undated for 
120 patients per month); Perpetual (undated for 30 patients each 
week); and Perpetual (undated for 60 patients each week). The 60- 
patient book consists of 256 pages of assorted blanks. The first three 
styles contain 32 pages of important data, thoroughly revised, and 
160 pages of assorted blanks. Each in one volume, price, $1.25. 
With thumb-letter index for quick use, 25 cents extra. Special rates 
to advance-paying subscribers to The Medical News or The 
American Journal of the Medical Sciences, or both. See p. 32. 


WATSON (THOMAS). LECTURES ON THE PRINCIPLES AND 
PRACTICE OF PHYSIC. A new American from the fifth and 
enlarged English edition, with additions by H. Hartshorne, M. D. 
In two large 8vo. vols. of 1840 pp., with 190 cuts. Cloth, $9 ; leather, $11. 

WEST (CHARLES). LECTURES ON THE DISEASES PECULIAR 
TO WOMEN. Third American from the third English edition. In 
one octavo volume of 543 pages. Cloth, $3.75; leather, $4.75. 

-ON SOME DISORDERS OF THE NERVOUS SYSTEM IN 

CHILDHOOD. In one small 12mo. volume of 127 pages. Cloth, $1. 

WHARTON (HENRY R.). MINOR SURGERY AND BANDAG¬ 
ING. New (4th) edition. In one 12mo. volume of 594 pages, with 
502 engravings, many of which are photographic. Just ready. $3.00, 
net. 


We know of no book which more 
thoroughly or more satisfactorily 
covers the ground of Minor Surgery 
and Bandaging. —Brooklyn Medical 
Journal. 

Well written, conveniently ar¬ 
ranged and amply illustrated. It 
covers the field so fully as to render 
it a valuable text-book, as well as a 


work of ready reference for sur¬ 
geons. —North Amer. Practitioner. 

The part devoted to bandaging is 
perhaps the best exposition of the 
subject in the English language. It 
can be highly commended to the 
student, the practitioner and the 
specialist.— The Chicago Medical 
Recorder. 







Lea Brothers & Co., Philadelphia and New York. 31 


WHITLA (WILLIAM). DICTIONARY OF TREATMENT, OR 
THERAPEUTIC INDEX. Including Medical and Surgical Thera¬ 
peutics. In one square octavo volume of 917 pages. Cloth, $4. 


WILLIAMS (DAWSON). THE 

DREN. In one 12mo. volume 
Just ready. Cloth, $2.50, net. 

The descriptions of symptoms are 
full, and the treatment recommended 
will meet general approval. Under 
each disease are given the symptoms, 


MEDICAL DISEASES OF CHIL- 
of 629 pages, with 18 illustrations. 

diagnoses, prognosis, complications, 
and treatment. The work is up to 
date in every sense.— The Charlotte 
Medical Journal. 


WILSON (ERASMUS). A SYSTEM OF HUMAN ANATOMY. 
A new and revised American from the last English edition. Illustrated 
with 397 engravings. In one octavo volume of 616 pages. Cloth, $4; 
leather, $5. 

-THE STUDENT’S BOOK OF CUTANEOUS MEDICINE. In 

one 12mo. volume. Cloth, $3.50. 

WINCKEL ON PATHOLOGY AND TREATMENT OF CHILDBED. 
Translated by James R. Chadwick, A. M., M. D. With additions 
by the Author. In one octavo volume of 484 pages. Cloth, $4. 

WOHLER’S OUTLINES OF ORGANIC CHEMISTRY. Translated 
from the eighth German edition, by Ira Remsen, M. D. In one 
12mo. volume of 550 pages. Cloth, $3. 


YEAR-BOOK OF TREATMENT FOR 1892, 1893, 1896,1897 and 1898. 
Critical Reviews for Practitioners of Medicine and Surgery. In con¬ 
tributions by 25 well-known medical writers. 12mos., about 500 pages 
each. Cloth, $1.50. In combination with The Medical News and 
The American Journal of the Medical Sciences, 75 cents. 


YEO (I. BURNEY). FOOD IN HEALTH AND DISEASE. New 
(2d) edition. In one 12mo. volume of 592 pages, with 4 engravings. 
Cloth, $2.50. See Series of Clinical Manuals , page 26. 


We doubt whether any book on 
dietetics has been of greater or more 
widespread usefulness than has this 
much-quoted and much-consulted 


work of Dr. Yeo’s. The value of 
the work is not to be overestimated. 
—New York Medical Journal. 


— A MANUAL OF MEDICAL TREATMENT, OR CLINICAL 
THERAPEUTICS. Two volumes containing 1275 pages. Cloth, $5.50. 


YOUNG (JAMES K.). ORTHOPEDIC SURGERY. In one 8vo. 
volume of 475 pages, with 286 illustrations. Cloth, $4; leather, $5. 

In studying the different chapters, |- surgical specialty and every page 
one is impressed with the thorough- abounds with evidences of prac- 
ness of the work. The illustrations ticality. It is the clearest and most 
are numerous—the book thoroughly modern work upon this growing de- 
practical— Medical News. ’ partment of surgery.— The Chicago 

It is a thorough, a very compre- Clinical Review. 
hensive work upon this legitimate 










PERIODICALS. 



PROGRESSIVE MEDICINE. 

A Quarterly Digest of New Methods, Discoveries, and Improvements 
in the Medical and Surgical Sciences by Eminent Authorities. Edited by 
Dr. Hobart Amory Hare. In four abundantly illustrated, cloth bound, 
octavo volumes, of 400-500 pages each, issued quarterly, commencing 
March 1st, 1899. Per annum (4 volumes), $10.00 delivered. 


THE MEDICAL NEWS. 

Weekly, #4.00 per Annum. 

Each number contains 32 quarto pages, abundantly illustrated. A 
crisp, fresh weekly professional newspaper. 


THE AMERICAN JOURNAL OF THE MEDICAL SCIENCES. 

Monthly, #4.00 Per Annum. 

Each issue contains 128 octavo pages, fully illustrated. The most 
advanced and enterprising American exponent of scientific medicine. 


THE MEDICAL NEWS VISITING LIST. 

Four styles, Weekly (dated for 30 patients); Monthly (undated, for 
120 patients per month); Perpetual (undated, for 30 patients weekly per 
year); and Perpetual (undated, for 60 patients per year). Each style in 
one wallet-shaped book, leather bound, with pocket, pencil and rubber. 
Price, each, $1.25. Thumb-letter index, 25 cents extra. 


THE MEDICAL NEWS POCKET FORMULARY. 


Containing 1600 prescriptions representing the latest and most ap¬ 
proved methods of administering remedial agents. Strongly bound in 
leather ; with pocket and pencil. Price, $1.50, net. 


COMBINATION RATES: 


American Journal of the 

Medical Sciences, 

z Medical News . 
z 

< Progressive Medicine 
g- Medical News Visiting List 
Medical News Formulary 


Alone. In Combination. 

# 4.00 -) __ l 

. 4.00 j $7.50 j $15.00 

. 10.00 J 

1.25 

. 1.50 net. 


In all #20.75 for #16.00 

First four above publications in combination . . #15.75 

All above publications in combination .... 16.00 

Other Combinations will be quoted on request. 

Full Circulars and Specimens free. 

i 


LEA BROTHERS & CO., Publishers, 

706, 708 & 710 Sansom St., Philadelphia. 

Ill Fifth Avenue, New York. 






























































